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General  Editor — JOHN  D.  COMRIE, 

M.A.,  B.Sc.,  M.D.,  F.R.C.P.E. 


PRACTICAL    PATHOLOGY 

INCLUDING    MORBID   ANATOMY   AND 
POST-MORTEM   TECHNIQUE 


IN  THE  SAME  SERIES 

TEXT-BOOK  OF  MIDWIFERY.  For 
Students  and  Practitioners.  By  R.  W. 
JOHNSTONE,  M.A.,  M.D.,  F.R.C.S., 
M  R.C.P.E.  Crown  8vo,  cloth,  with 
264  Illustrations  (3  coloured).  Price 
$3.25  net. 

DISEASES  AND  INJURIES  OF  THE 
EVE.  A  Text-Book  for  Students  and 
Practitioners.  By  WM.  GEORGE  SYM. 
M.D.,  F.R.C.S.E.  Containing  25  Full- 
page  Illustrations,  16  of  them  in  colour, 
and  88  Figures  in  the  Text;  also  a  Type 
Test-Card  at  end  of  Volume.  Small 
crown  8vo,  cloth.  Price  $2.50  ret. 


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PRACTICAL      PATHOLOGY 

INCLUDING 

MORBID  ANATOMY 

AND 

POST-MORTEM  TECHNIQUE 


BY 

JAMES   MILLER 

M.D.,  D.Sc./F.R.C.  P.E. 


LECTURER  ON  PATHOLOGY  AND  BACTERIOLOGY,  SCHOOL  OF  MEDICINE 
OF  THE  ROYAL  COLLEGES,  EDINBURGH,  AND  EDINBURGH  SCHOOL  OF 
MEDICINE  FOR  WOMEN;  EXAMINER  IN  PATHOLOGY,  UNIVERSITY  OF 
ABERDEEN  AND  ROYAL  COLLEGE  OF  PHYSICIANS,  EDINBURGH; 
PATHOLOGIST,  ROYAL  VICTORIA  HOSPITAL,  ROYAL  HOSPITAL  FOR 

INCURABLES,  AND  DEACONESS  HOSPITAL,  EDINBURGH;  ASSISTANT 
PATHOLOGIST,  ROYAL  INFIRMARY,  AND  ROYAL  MATERNITY  HOSPITAL, 
EDINBURGH;  LATB  VISITING  PATHOLOGIST,  GENERAL  HOSPITAL, 
BIRMINGHAM;  LECTURER,  BIRMINGHAM  UNIVERSITY,  EXAMINER  IN 

PATHOLOGY,   UNIVERSITY    OF    ST.   ANDREWS 


JJeto 

THE   MACMILLAN   COMPANY 
1914 

All  rights   reserved 


'  \ 


PREFACE 

THE  object  of  this  volume  is  to  give  the  student  of  medicine 
and  the  practitioner,  in  a  handy  form,  the  information 
required  for  practical  work  in  relation  to  Pathology.  There 
will  be  found  short  descriptions  of  the  appearances  in  the 
more  common  morbid  processes  to  be  met  with  in  the 
organs  and  tissues  ;  at  the  same  time  these  are  co-related 
with  the  changes  in  the  other  organs  and  tissues  of  the  body 
in  the  various  diseases.  The  main  points  in  the  microscopic 
appearances  are  also  given  very  shortly,  merely  in  order  to 
remind  the  student  what  he  should  look  for  when  going  over 
his  slides.  In  dealing  with  post-mortem  technique,  fixing 
and  mounting  of  preparations,  cutting  and  staining  of 
sections,  the  endeavour  has  been  to  give  one  reliable  method 
in  every  case,  rather  than  numerous  alternative  methods. 
Hence  the  book  is  not  one  for  the  specialist.  The  chapter 
on  Tumours  is  added  to  supplement  the  necessarily  short 
descriptions  of  neoplasms  under  the  heading  of  the  various 
organs.  For  the  benefit  of  the  practitioner,  a  short  chapter 
dealing  with  the  medico-legal  aspects  of  post-mortem  work 
has  been  included.  Owing  to  the  frequent  occurrence  of 
cross  references,  it  was  decided  to  bind  the  illustrations 
together  in  the  form  of  an  atlas  at  the  end  of  the  book. 
Illustrations  of  microscopic  preparations  have  been  omitted, 
as  the  student  has  his  slides  to  which  he  can  refer. 

The  author  has  made  extensive  use  of  volumes  such  as  Sims 
Woodhead's  Practical  Pathology ;  Shennan's  Post-Mortems 
and  Morbid  Anatomy,  Orth's  Pathologisch  -  anatomische 
Diagnostik  and  Erlduterungen  zu  den  Vorschriften  fur  das 
Verfahren  der  Gerichtsdrzte  bei  den  gerichtlichen  Untersuchungen 
menschlicher  Leichen ;  Herxheimer's  Grundriss  der  patho- 


VI 


PREFACE 


logischen  Anatomic  and  Technik  der  pathologisch-histologischen 
Untersuchung ;  Mann's  Physiological  Histology ;  Mallory 
and  Wright's  Pathological  Technique ;  Letulle's  La  Pratique 
des  autopsies ;  Adami's  various  works  ;  Beattie  and  Dickson's 
Pathology ;  Pembrey  and  Ritchie's  General  Pathology ;  also 
Lorrain  Smith  and  Mair's  classical  work  on  staining  methods 
for  fats  in  the  Journal  of  Pathology  and  Bacteriology. 

To  the  personal  teaching  of  Professors  Greenfield,  Muir, 
and  Leith,  and  of  the  late  Professors  Ziegler  and  Weigert, 
a  deep  debt  of  gratitude  is  also  due. 

The  author  has  great  pleasure  in  expressing  his  indebted- 
ness to  Professor  Harvey  Little  John  for  invaluable  help  in 
preparing  the  chapter  on  medico-legal  post-mortems  and  for 
his  permission  to  use  two  typical  post-mortem  reports.  His 
thanks  are  also  due  to  Dr.  John  Fraser  for  revising  the 
chapter  on  diseases  of  bones  ;  to  Dr.  James  Young  for  many 
suggestions  in  Chapter  XII. ;  to  Dr.  W.  G.  Porter  for  assistance 
in  preparing  Figure  12  ;  to  Dr.  Sidney  Smith  for  the  use  of 
his  fine  preparations  illustrating  centres  of  ossification  in  the 
infant  in  connection  with  the  table  on  p.  309  ;  also  to  .Mr.  W. 
Waldie  of  the  Royal  College  of  Surgeons'  Museum,  Edinburgh, 
for  his  advice  as  to  the  fixing  and  mounting  of  specimens. 

The  illustrations  have,  with  one  or  two  exceptions,  been 
made  by  Mr.  Glass  from  preparations  in  the  author's  collection. 
For  the  care  and  trouble  taken,  the  author  wishes  to  express 
his  hearty  thanks.  If  acknowledgment  has  not  in  every 
instance  been  made  to  the  physician  or  surgeon  who  had 
charge  of  the  case,  the  author  begs  to  offer  his  apologies. 
His  thanks  are  due  to  Professor  Sutherland  for  the  specimen 
from  which  Fig.  33  was  drawn. 

For  much  useful  advice  and  criticism,  I  have  to  thank 
the  Editor  of  the  Edinburgh  Medical  Series — Dr.  J.  D. 
Comrie.  For  reading  the  proofs  and  for  drawing  up  the 
index,  I  have  to  express  my  hearty  thanks  to  my  assistant, 
Dr.  Fergus  Hewat. 

J.  M. 

SURGEONS'  HALL,  EDINBURGH, 
October  27,  1913. 


CONTENTS 

CHAPTER    I 


PAGE 

INTRODUCTORY  ...  i 


CHAPTER    II 

EQUIPMENT  OF  THE  PATHOLOGIST              .  .  ,           5 

CHAPTER    III 

METHOD  OF  PROCEDURE     .             .             .  .  .13 

Removal  of  Thoracic  Contents    .              .  .  .22 

Removal  of  Abdominal  Contents               .  .  .28 
Removal  of  the  Brain     .....          35 

Removal  of  the  Spinal  Cord        .              .  .  -39 

CHAPTER    IV 

DISEASES  OF  THE  HEART  AND  PERICARDIUM  .  '  f        46 

Malformation  of  the  Heart  and  Great  Vessels  .  .         46 

Diseases  of  the  Pericardium         .              .  .  .         48 

Diseases  of  the  Myocardium         .             .  ,.  •         53 

Diseases  of  the  Endocardium       .              .  V  «"         60 

Effect   on    the   Heart    and   Circulation    of   the  Different 

Types  of  Chronic  Valvular  Disease      .  ..  •          69 
vii 


viii  CONTENTS 

CHAPTER   V 

PAGE 

DISEASES  OF  THE  VESSELS  ...  77 

Diseases  of  the  Arteries  .  .  .  .  •       .  77 

Diseases  of  Veins  .  .  .  «  •         %7 


CHAPTER   VI 

DISEASES  OF  THE  BLOOD,  BONE  MARROW,  LYMPH  GLANDS, 

SPLEEN,  AND  DUCTLESS  GLANDS      .  .         .   .  91 

Diseases  of  the  Blood      .              .              .  .             .  91 

Haemorrhagic  Diseases    .             .             .  .              «  99 

Diseases  of  the  Bone  Marrow      .             •  .              .  100 

Diseases  of  Lymph  Glands          .          ,  ,.  .             .  102 

Diseases  of  the  Spleen    .              .             .  •  IO5 

Diseases  of  the  Thyroid  Gland    .  J  .             .  1 1 1 

Diseases  of  the  Thymus  Gland    .              .  ...  113 

Diseases  of  the  Suprarenal  Glands            .  .           „ .  113 


CHAPTER    VII 

DISEASES  OF  THE  RESPIRATORY  SYSTEM     .  .  .116 

Diseases  of  the  Larynx   .              .              .  .  .116 

Diseases  of  the  Bronchi  .              .              .  .  .117 

Diseases  of  the  Lungs     .              .              .  .  .119 

Diseases  of  the  Pleura     .              .              .  .  .149 


CHAPTER    VIII 

DISEASES  OF  THE  INTESTINAL  TRACT  AND  PERITONEUM  .       153 

Diseases  of  the  Stomach                .              .              .  .154 

Diseases  of  the  Intestine               .              .              .  159 

Diseases  of  the  Peritoneum          .              .              .  .172 


CONTENTS  ix 

CHAPTER    IX 

PAGE 

DISEASES  OF  THE  LIVER,  BILE  PASSAGES,  AND  PANCREAS       175 
Diseases  of  the  Liver      .  .  .  .  .175 

Diseases  of  the  Gall  Bladder  and  Bile  Ducts         .  .194 

Diseases  of  the  Pancreas  .  .  .  .197 

CHAPTER    X 

DISEASES  OF  THE  KIDNEY  AND  BLADDER  .  .  .       200 

Diseases  of  the  Kidney   .....        200 
Diseases  of  the  Pelvis  of  the  Kidney         .  .  .225 

Diseases  of  the  Urinary  Bladder  .  .  .227 

CHAPTER   XI 

DISEASES  OF  THE  BRAIN  AND  SPINAL  CORD  AND  THEIR 

MEMBRANES  ......  229 

Diseases  of  the  Brain       .....  233 

Diseases  of  the  Spinal  Cord         ....  244 

Diseases  of  the  Cord  to  which  Special  Names  are  given  .  248 

Diseases  of  the  Peripheral  Nerves  .  .  .  252 

CHAPTER    XII 

DISEASES  OF  BONES  AND  JOINTS     ....       254 
Diseases  of  Bones  .  .  .  .  .254 

Diseases  of  Joints  .  .  .  .  .261 

CHAPTER    XIII 

DISEASES  OF  THE  REPRODUCTIVE  ORGANS  AND  MAMMARY 

GLAND — DISEASES  OF  PREGNANCY   .  .  .       264 

Diseases  of  the  Ovaries   .  .  .  .  .264 

Diseases  of  the  Fallopian  Tubes  .  .  .        265 

Diseases  of  the  Uterus    .....        266 


x  CONTENTS 

PAGE 

Diseases  of  the  Placenta                             ,  268 

Diseases  of  Pregnancy  and  the  Puerperium           .  ,  269 

Diseases  of  the  Mammary  Gland               .              .  .272 

Diseases  of  the  Testicle  .              .              ...  .  273 

Diseases  of  the  Prostate .              .              .  ,          .  .274 

CHAPTER    XIV 

TUMOURS     .            .            .            .                        .  .  275 

Simple  Tumours              .              .              .              .  .  277 

Malignant  Tumours         *             .  •           .              .  .  286 

Teratomata         .             .             .             .             .  ".  303 

CHAPTER   XV. 

POINTS  TO   BE   REMEMBERED  IN   PERFORMING  AUTOPSIES 

ON  CASES  WITH  A  MEDICO-LEGAL  ASPECT.  .  306 

General  Method  of  Procedure  in  Medico-Legal  Cases  .  306 

Post- Mortems  on  Newly- Born  Infants      .              .  .  308 

Post- Mortem  Changes  produced  by  Poisons          .  .  311 

Specimen  Post-Mortem  Reports  .              .              .  315 

APPENDIX 

TREATMENT  OF  SPECIMENS  FOR  MOUNTING            .  .  319 

TREATMENT  OF  TISSUES  FOR  MICROSCOPIC  PURPOSES  .  324 

STAINING  METHODS             .             .            ;            .  .  337 

MAKING  OF  BLOOD  FILMS  .            .            .            .  .  357 

BACTERIOLOGICAL  METHODS  OF  INVESTIGATION     .  358 
EXAMINATION  OF  SPUTUM,  Pus,  ETC.,  FOR  THE  TUBERCLE 

BACILLUS          .            .            .            .            .  .  370 

THE  BACTERIOLOGICAL  DIAGNOSIS  OF  DIPHTHERIA  .  372 

AGGLUTINATION  TEST  FOR  ORGANISMS       .            .  .  374 

METHOD  OF  MAKING  PIPETTES       ....  375 

EMBALMING             .            .            .            .            .  .  376 

INDEX      •  .    '                      .             .             .             .  .  377 


LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

Sections  of  liver  and  kidney  (in  colour}     .  .        Frontispiece 

Plan  of  the  circulation  to  show  the  origin  and  destination 

of  the  more  common  emboli     ...  62 

Plan  of  the  circulation  in  the  kidney         .  .  .        206 

1 .  Method  of  opening  the  abdominal  cavity  .  .  ^ 

2.  Reflecting  the  skin  and  muscles  from  the  sternum  and  ribs/ 


3.  Method  of  cutting  through  sterno-clavicular  joint  . 

4.  Method  of  cutting  through  floor  of  mouth 


'}  398 

5.  Lines  of  incisions  for  opening  up  the  cavities  of  the  heart 

6.  Method  of  incising  the  lung 

7.  Method  of  opening  the  coronary  arteries  . 

8.  Method  of  testing  the  competence  of  the  sernilunar  valves  .  J 

9.  Method  of  removing  the  small  intestine    . 


}    399 


401 

10.  Method  of  opening  the  bowel  after  it  has  been  removed 

11.  Cutting  through  tentorium  cerebelli  in  removing  the  brain  \ 

12.  Position  of  the  accessory  cavities  in  relation  to  the  base  r    4°2 

of  the  skull     .  .  .  .  .  J 

13.  Method  of  incising  the  kidney      .  .  .  .  ^ 

14.  Method  of  stitching  up    .  .  .  .  ./ 

15.  Heart,  acute  pericarditis  .  .  .  .  \ 

1 6.  Acute   aneurysm    following   abscess    of   left    ventricle    in  r    4°4 

case  of  osteomyelitis  .  .  i  .J 

17.  Heart,  chronic  interstitial  myocarditis       .  .  .  ^ 

1 8.  Section  through  wall  of  right  ventricle,  showing  increase  I 

of  sub-pericardial  fat  and  fatty  infiltration  of  the  muscle  j 

19.  Thrombus  in  right  auricular  appendix       .  •  .-  .  J 

xi 


xii  LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

20.  Simple  (vegetative)  endocarditis  in  a  case  of  chorea,  heart 

of  child  ......        406 

21.  Simple  endocarditis,  aortic  valve  .  .  .  ^ 

22.  Heart,  ulcerative  endocarditis  of  mitral  valve        .  .  J 

23.  Ulcerative  endocarditis,  aortic  valve          .  .  .  ^ 

24.  Transverse  section  of  heart,  showing  hypertrophy  of  the  r    4°8 

left  ventricle  in  case  of  chronic  interstitial  nephritis       .  J 

25.  Anterior   aspect    of   heart   from   case   of  mitral    stenosis,^ 

showing  dilatation   of  right    auricle    and   well-marked 

hypertrophy  as  well  as  dilatation  of  right  ventricle 

,    409 

26.  Same    heart    from    above,    showing    dilatation    of    both  I 

auricles.      The    narrowed    mitral    valve    (button -hole) 
can  be  seen     .  .  .  .  .  .  J 

27.  Chronic  endocarditis  of  aortic  valve,  with  stenosis  .~\ 

28.  Portion  of  descending  thoracic  aorta,  showing  atheroma    .  I    410 

29.  Arteries  at  base  of  brain,  showing  atheroma  ,  .J 

30.  Saccular  aneurysm  of  descending  aorta  adherent  to  and 

eroding  the  bodies  of  the  vertebrae       ".  .  .        411 

31.  Spleen   considerably   enlarged  from   chronic   venous   con-^i 

gestion,  showing  infarcts 

32.  Spleen,  myelogenous  leukaemia  and  infarction        .  .  j 

33.  Spleen,  tuberculous  masses  ".  .  .  .  J 

34.  Spleen  and  spleniculus,  sago  waxy  .  .  .->, 

35.  Spleen,   Hodgkin's  disease,   showing    numerous  scattered 

white  masses  varying  in  size    .  .  .  .  I    413 

36.  Spleen,  Hodgkin's  disease,  showing  white  masses  arranged  I 

in  groups         .  .  .  .  .  .  J 

37.  Mass  of  tuberculous  lymphatic  glands  in  section,  showing 

numerous  caseous  foci  .  .  .  ' 

38.  Lymphatic  glands,  lymphadenoma  (Hodgkin's  disease)  . 

39.  Thyroid  gland,  exophthalmic  goitre          .  . 

40.  Lung,  emphysema  .  .  .  .  ./ 

41.  Lung,  collapse  due  to  empyema  .  .  .  .416 

42.  Lung,  lobar  pneumonia  .  .  .  .  .417 

43.  Lung  and  bronchi,  showing  acute   bronchitis  and  septic 

broncho-pneumonia     .  .  .  ,  .        418 


LIST  OF  ILLUSTRATIONS  xiii 


PAGE 


44.  False  membrane  in  trachea  in  diphtheria  .  .  ^ 

45.  Portion  of  lung,  showing  two  recent  infarcts  .  .  v    419 

46.  Lung,  gangrene  .  .  .  .  .  .  J 

47.  Lung,  silicosis     .  .  .  .  .  .        420 

48.  Lung,  anthracosis  .... 

40.    Lung,  acute  miliary  tuberculosis  . 

h    421 

50.  Mediastinal  glands  and  lung   of  infant,   showing  caseous 

tuberculosis     ..... 

51.  Lung,  caseous  (tuberculous)  pneumonia  with  cavitation     .        422 

52.  Lung,    chronic    tuberculosis,    with    cavity    in    which    an'' 

aneurysm  has  formed  .... 

53.  Lung,   fibro-caseous   tuberculosis,   with  marked    tendency  V    423 

to  healing        ..... 

54.  Surface  of  lung,  acute  pleurisy 

55.  Section    of  lung,    showing    large    number   of   nodules   of\ 

secondary  carcinoma    .  .  .  .  .1 

56.  Lympho-sarcoma  of  the  mediastinal  glands  invading  the  | 

root  of  the  lung  .  .  .  .  .  / 

57.  Squamous  epithelioma  of  oesophagus,  with  marked  narrow- 

ing of  lumen  ...... 

58.  Peptic  ulcer  of  stomach,  with  opening  into  vessel  in  floor       425 

of  ulcer  .  . 

59.  Large  duodenal  ulcer       .... 

60.  Stomach    opened    up    anteriorly    to    display    encephaloid 

cancer  close  to  cardiac  opening  .  .  .        426 

61.  Intussusception    of    small    intestine    and    mesentery    into 

large  intestine  ..... 

62.  Typhoid  lesion  of  small  intestine  (early  stage) 


63.  Typhoid  lesion  of  small  intestine  (later  stage) 

64.  Tuberculous  ulcer  of  small  intestine 

65.  Tuberculous    ulcer,     peritoneal    aspect,    showing    raised 

tubercles  under  peritoneum      .  .'  . 

66.  Large  intestine,  ulcerative  colitis  (dysentery)         . 

67.  Portion  of  large  bowel  from  case  of  amoebic  dysentery, 

showing  characteristic  early  lesion 


427 


xiv  LIST  OF  ILLUSTRATIONS 

FIG. 

68.  Acute  appendicitis  and  peritonitis 

69.  Pelvic     colon,     with     adeno-carcinoma     projecting     into  j*    429 

interior  ..... 

70.  Peritoneal  aspect  of  loop  of  intestine,  showing  tuberculous  \ 

peritonitis        .  .  j.    430 

71.  Abscesses  of  liver,  portal  pysemia  type 

72.  Liver,    large   tropical   abscess,   with  much  necrotic  liver' 

tissue  ...... 

73.  Liver    of    child,    showing    multiple    nodular   hyperplasia 


(regeneration    of  liver    substance)  following    an    acute 


431 


degenerative  process 

74.  Liver,  common  cirrhosis 

75.  Liver,  showing  group  of  gummata  .  .  .^ 

76.  Liver,  cavernous  angioma  .  .  .  .  V    432 

77.  Section  of  liver  with  secondary  deposits  of  sarcoma  .  J 

78.  Liver,  greatly  enlarged,  with  numerous  secondary  nodules> 

of  carcinoma  .  .  ... 

v     433 

79.  Section  of  liver,  with  hydatid  cyst  from  which  numerous 

smaller  cysts  are  protruding     .  .  .  .  J 

So.   Biliary  calculi  or  gall-stones          .  .  .  .  ^ 

81.  Congenital  cystic  kidney  .  .  .  .1    434 

82.  Infarcts  of  the  kidney      .  .  .  .  .  J 

83-86.   Kidneys    illustrating    the    various    types    of    Bright's 

Disease  ......        435 

87,  88.   Kidney,  pyaemic  abscesses  .  .  .  .  ^ 

89,  90.   Kidney,  tuberculosis  .  .  .  ,f 

91.  Kidney,  hydronephrosis  .  .  .  .  .\ 

92.  Kidney,  hypernephroma  .  .  .  .  .  I    437 

93.  Coralline  calculus  in  kidney  .  .  .  .  J 

94.  Brain,  showing  acute  meningitis  .  .  .  .  ^ 

95.  Brain,  tuberculous  meningitis  .  .  .  .  / 

96.  Section  of  brain,  showing  acquired  hydrocephalus  .  -j 

97.  Section   of  brain,   showing   haemorrhages   into   the   basal  f    439 

ganglia  on  right  side  .  .  .  .  .  J 


440 


LIST  OF  ILLUSTRATIONS  xv 


98.  Cerebellum,    with    depressed    areas    from    softening    of" 

brain  substance  due  to  thrombosis  in  arteries    . 

99.  Vertical    section    of   brain,   showing   solitary   abscess   in 

temporo-sphenoidal  lobe  .... 

100.  Transverse   section  of  pons,   showing  haemorrhages  into 

its  substance   . 

101.  Cholesteatoma  in  frontal  lobe     .  A 

102.  Teratoma    (dermoid)    of    ovary    containing     sebaceous  [ 

material  and  hairs.     Solitary  cyst  above  it  .1 

103.  Scirrhous  cancer  of  the  breast,  with  indrawing  of  nipple   J 

104.  Myomata  in  wall  of  uterus          .  .  .  .  ^ 

105.  Enlargement  of  costo-chondral  junctions  (rickety  rosary)  r    442 

in  rickets         .  .  .  .  .  .  J 

1 06.  Osteomyelitis  of  lower  end  of  femur        .  .  .\ 

107.  Lower  lumbar  vertebrae  and  sacrum  in  section,  showing  r    443 

tuberculous  disease  of  bodies  and  psoas  abscess  .  J 

1 08.  Osteo-sarcoma  of  shaft  of  femur  .  .  .^\ 

f    444 

109.  Myeloid  sarcoma  of  jaw  .  .  .  .  J 


PRACTICAL    PATHOLOGY 

CHAPTER   I 

INTRODUCTORY 

THE  post-mortem  examination,  sectio  cadaveris,  or  autopsy 
is  an  essential  part  of  the  scientific  investigation  of  all  fatal 
cases  of  disease.  It  is  obvious  that  only  by  its  means  can 
the  medical  man  acquire  an  accurate  knowledge  of  the  nature, 
extent,  distribution,  and  complications  of  a  morbid  condition. 
It  is  not  too  much  to  say  that  however  plain  and  simple  the 
diagnosis  of  a  disease  may  be,  some  additional  light  will  be 
thrown  upon  the  case  at  the  post-mortem  examination.  In 
a  very  considerable  number  of  instances,  conditions  quite 
unexpected  during  life  will  be  found,  and,  in  a  few,  the 
diagnosis  of  the  clinician  will  be  entirely  upset  by  the  patholo- 
gist 's  investigations. 

A  post-mortem  examination  should  therefore  be  performed 
whenever  feasible.  Further,  the  examination  should  be  as 
thorough  as  possible  :  should,  in  other  words,  include  as 
many  parts  of  the  body  as  possible,  and  should  be  followed 
by  microscopic,  and,  if  necessary,  bacteriological  examination 
of  the  diseased  organs  and  tissues.  In  not  a  few  instances 
the  pathologist's  view  of  a  case  obtained  by  naked-eye 

i  i 


2  INTRODUCTORY 

examination  alone  is  greatly  altered  by  subsequent  micro- 
scopic or  bacteriological  investigation. 

For  example,  in  a  case  which  came  under  the  author's 
notice  there  was  a  stricture  of  the  small  intestines  which, 
from  the  clinical  history  as  well  as  from  the  naked-eye  appear- 
ances, was  believed  to  be  malignant.  Microscopic  examina- 
tion showed  the  condition  to  be  tuberculous. 

In  another  case,  where  haemorrhagic  infiltration  of  the 
mediastinal  tissues  was  the  main  post-mortem  finding,  the 
true  nature  of  the  disease  was  only  found  on  making  cultures, 
when  a  pure  growth  of  the  anthrax  bacillus  was  obtained,  the 
case  proving  to  be  one  of  "  woolsorter's  disease." 

From  another  point  of  view  a  post-mortem  examination 
may  be  required;  that  is  the  medico-legal.  Cases  of  suspected 
poisoning  may  prove  to  be  ordinary  diseased  conditions, 
and,  vice  versa,  cases  where  foul  play  is  unsuspected  may  turn 
out  to  be  due  to  poisoning. 

To  give  another  example  from  the  author's  experience. 
A  well-to-do  contractor  died  suddenly  with  symptoms  of 
severe  jaundice.  His  will  was  known  to  be  drawn  out  in 
favour  of  the  foreman  of  his  works,  with  whom  he  lived.  The 
medical  attendant  considered  phosphorous  poisoning  a  possi- 
bility, but  post-mortem  examination  revealed  the  presence  of  a 
large  impacted  calculus  in  the  common  bile  duct. 

In  all  cases  of  sudden  death  where  the  cause  is  unknown, 
or  of  violent  or  suspected  violent  deaths,  notice  must  be  sent 
at  once  to  the  Procurator-Fiscal  or  Coroner.  Such  bodies 
become  the  property  of  the  Fiscal  or  Coroner,  and  cannot  be 
touched  without  his  consent.  (For  further  information  on 
this  point  see  Chapter  XV.) 

Precautions  to  be  taken. — Before  proceeding  in  any 
way  to  carry  out  a  post-mortem  examination,  it  is  absolutely 
necessary  that  the  permission  of  the  nearest  relative  of  the 
deceased  be  obtained.  In  certain  hospitals,  more  happily 
situated  than  their  fellows,  the  regulation  is,  that  unless 


INTRODUCTORY  3 

notice  to  the  contrary  be  received  from  the  relatives  within 
twenty-four  hours  of  the  death  of  the  patient,  an  autopsy 
will  be  performed.  This  is  a  far  better  system  than  the  one 
under  which  permission  has  to  be  asked  for  in  each  case. 
When  not  confronted  with  the  choice,  the  relatives,  as  a  rule, 
except  in  the  case  of  certain  religious  creeds,  think  little  of 
the  matter.  When  permission  is  asked  for,  they  at  once 
begin  to  conjure  up  visions  of  mutilation,  and  it  requires  in 
most  instances  no  little  tact  on  the  part  of  the  medical  man 
to  obtain  permission.  In  every  case,  however,  where  leave 
has  to  be  asked,  it  should  be  obtained  in  writing  from  the 
nearest  relative.  The  absolute  necessity  for  this  precaution, 
if  the  doctor  is  to  protect  himself,  has  been  emphasised  on 
several  occasions  recently  in  the  law  courts.  In  a  case  tried 
before  the  Court  of  Session  in  Edinburgh,  the  judge,  in 
charging  the  jury,  said  that  the  holding  of  an  unauthorised 
post-mortem  "  gave  a  legal  remedy/'  and  that  when  per- 
formed without  consent  "  the  case  would  be  treated  very 
smartly  "  ;  further,  the  defender,  a  medical  man  who  had 
performed  the  sectio, "  would  have  been  well  advised  had  he 
obtained  permission  from  the  father  in  writing" 

Medico-legal  Cases. — When  the  case  is  a  medico-legal 
one,  it  is  necessary  to  receive  permission  from  the  Procurator- 
Fiscal  (Scotland)  or  the  Coroner  (England)  before  a  post- 
mortem examination  is  performed.  This  permission  having 
been  obtained,  none  other  is  required.  Although  in  all  cases 
it  is  advisable  to  take  full  notes  at  the  time,  these  should  be 
taken  with  special  care  in  cases  which  have,  or  are  likely  to 
have,  a  medico-legal  aspect  (e.g.  workmen's  compensation 
cases). 

In  certain  cases  with  a  medico-legal  aspect  the  Coroner 
or  Fiscal  will  order  an  autopsy  to  be  performed.  When 
reporting  such  a  case  the  pathologist  should  avoid  as  far  as 
possible  the  use  of  technical  terms.  In  Scotland  such  a 


4  INTRODUCTORY 

report  requires  to  be  drawn  up  in  what  is  known  as  the 
"  soul  and  conscience  form  "  (see  Chapter  XV.). 

Importance  of  Post-mortem  Change. — It  is  quite  obvious 
that  the  sooner  the  post-mortem  examination  is  carried 
out  after  the  death  of  the  patient  the  better,  but  unless 
there  is  any  special  reason  to  the  contrary  it  is  usual  to  wait 
for  twenty-four  hours. 

The  changes  which  begin  to  take  place  in  a  body  after  death 
tend  to  mask,  and  eventually  to  obliterate  entirely,  the 
characteristic  appearances  of  most  pathological  conditions. 
Diseased  conditions  have  been  found  in  Egyptian  mummies, 
and  caries  of  teeth  and  evidence  of  rickets  in  the  skeletons  of 
prehistoric  men,  but  as  a  rule  the  softer  parts,  and  more  parti- 
cularly the  hollow  viscera  and  abdominal  organs,  rapidly  lose 
the  characteristic  signs  of  disease  through  decomposition. 
The  extent  and  rapidity  of  this  change  will,  of  course,  depend 
upon  circumstances.  The  processes  take  place  much  more 
rapidly  in  warm  weather.  Conversely  in  cold  weather,  or  if, 
as  is  possible  in  some  hospitals,  the  bodies  are  placed  in  an 
apparatus  artificially  cooled,  they  will  retain  their  freshness 
for  a  much  longer  period.  Another  factor  bearing  upon  this 
is  the  disease  from  which  the  patient  has  died.  In  septic 
conditions,  more  particularly  in  the  abdominal  cavity, 
decomposition  occurs  more  quickly,  and  tends  to  alter  the 
appearance  of  organs  in  the  neighbourhood. 


CHAPTER  II 

THE  EQUIPMENT  OF  THE  PATHOLOGIST 

Rubber  Gloves. — One  of  the  most  important  parts  of  the 
pathologist's  equipment  is  a  good,  sound  pair  of  rubber 
gloves.  Fifteen  or  twenty  years  ago  gloves  were  seldom 
worn.  In  consequence,  those  carrying  out  post-mortem 
work  suffered  periodically  from  septic  wounds,  if  not  from 
the  more  serious  infections,  such  as  tuberculosis.  Nowadays 
there  is  no  excuse  for  such  accidents,  as  gloves  are  cheap, 
and  with  care  they  last  a  considerable  time.  The  best  type 
of  glove  is  the  thin  rubber  glove  used  by  the  surgeon.  The 
thicker  ones  naturally  last  longer,  but  they  are  more  expensive, 
more  difficult  to  work  with,  and  are  more  troublesome  to 
mend. 

It  is  very  necessary  that  the  pathologist  should  care  for 
his  gloves,  seeing  so  much  depends  upon  them.  During  a 
post-mortem  the  gloves  should  be  frequently  washed  under 
running  water  to  prevent  the  drying  of  blood  or  pus  upon 
their  surface.  After  the  operation  is  finished,  they  should 
be  washed  while  on  the  hands,  first  with  soap  and  water,  and 
then  with  water  alone,  afterwards  dried,  and  while  still  on 
the  hands  moistened  all  over  with  biniodide  of  mercury 
spirit  (biniodide  of  mercury  i  part,  methylated  spirit 
500)  and  dried  again  with  a  towel.  If  punctured,  the 

5 


6       THE  EQUIPMENT  OF  THE  PATHOLOGIST 

interior  of  the  glove  should,  of  course,  be  similarly  treated. 
The  exact  position  of  a  puncture  can  be  found  by  distending 
the  glove  with  water.  A  patch  can  then  be  applied,  just  as 
one  mends  a  punctured  tyre.  The  gloves  should  subsequently 
be  folded  up  and  placed  in  the  cardboard  box  supplied  with 
them. 

If  long  intervals  elapse  between  post-mortems,  the  gloves 
may  become  hard  and  brittle.  A  few  minutes'  immersion  in 
hot  water  will  make  them  soft  again. 

Where  gloves  are  not  obtainable,  the  hands  may  be  smeared 
with  carbolic  oil. 

Post-mortem  Wounds. — In  the  case  of  a  punctured 
wound  obtained  at  a  post-mortem  it  is  well  to  wash  the  part 
thoroughly  in  warm  water,  suck  it,  and  then  dress  it  with 
some  weak  antiseptic,  such  as  i  :  40  carbolic.  Some  recom- 
mend the  use  of  pure  carbolic  or  other  strong  acid  in  the 
first  instance.  If  slight,  the  wound  can  be  covered  with  a 
layer  of  celloidin  dissolved  in  equal  parts  of  alcohol  and 
ether,  or  with  "  new  skin." 

In  his  movements  with  knife  or  needle,  the  pathologist 
should  always  be  slow  and  cautious.  When  dealing  with 
purulent  or  other  infective  fluid,  or  with  faecal  material, 
great  care  should  be  taken  not  to  splash  it  about.  Severe 
eye  infections  sometimes  result  in  this  way,  and  the  author 
knows  of  cases  in  which  typhoid  infection  resulted  from  the 
splashing  of  infected  faeces.  For  this  reason  it  is  well  to 
avoid  using  a  strong  stream  of  water  when  washing  intestines, 
or,  indeed,  at  any  time. 

Eye  Infections.  —  When  some  foreign  material  has 
entered  the  eye,  the  conjunctival  sac  should  be  washed  out 
with  a  little  warm  saline.  The  method  of  washing  out  is  to 
place  the  individual  on  a  chair  with  head  well  thrown  back, 
and  to  squeeze  the  saline  fluid  into  the  eye  with  a  piece  of 
cotton  wool.  There  is  no  need  to  use  an  antiseptic,  as  the 


THE  EQUIPMENT  OF  THE  PATHOLOGIST   7 

conjunctival  sac  can  of  itself  destroy  a  considerable  amount 
of  infective  material.  The  object  of  the  washing  is  merely 
to  remove  as  much  of  the  irritant  as  possible.  In  any  case 
the  eye  should  not  be  rubbed  or  irritated  in  any  way. 

Another  source  of  danger  for  the  pathologist  is  flies. 
These  are  excessively  troublesome  in  warm  climates,  and  are, 
undoubtedly,  a  means  of  conveying  infection.  Fly-papers 
will  be  found  useful  in  reducing  the  number. 

Turning  to  the  question  of  instruments,  these  need  not  be 
numerous  or  elaborate.  The  following  are  essential : — 

Instruments. — i.  A  sharp  large-bladed  knife  for  making 
incisions  in  the  skin  and  for  removing  organs.  Several  of 
these  should  be  kept. 

2.  A  long,  flat  knife  for  cutting  into  the  solid  organs. 

3.  A  straight  probe-pointed  bistoury  for  opening  the  heart, 
the  smaller  vessels,  such  as  the  coronary  arteries,  for  opening 
the  bronchi,  and  for  incising  the  dura  and  cutting  nerves  in 
removing  the  brain. 

4.  A  pair  of  dissecting  forceps  for  finer  work. 

5.  A  pair  of  fairly  large  round-ended  scissors  for  opening 
the  bowel.    These  may  be  of  the  special  type  commonly 
used,  but  an  ordinary  pair,  provided  the  edges  are  sharp  and 
the  ends  blunt,  will  do  almost  equally  well. 

6.  A  good  saw,  with  removable  back. 

7.  A  chisel. 

8.  A  wooden  or  soft  metal  mallet. 

9.  Several  flexible  probes. 

10.  A  packing  needle. 

11.  Strong  twine. 

12.  Wooden  cones  for  measuring  the  diameter  or  circum- 
ference   of    the    heart    valves   (e.g.   those    advocated    by 
Shennan)  will  be  found  useful. 

In  addition  it  is  well  to  have  one  or  more  sharp-pointed 
scalpels  for  any  finer  dissection  that  may  be  required  ;  also  a 


8       THE  EQUIPMENT  OF  THE  PATHOLOGIST 

pair  of  small  sharp-pointed  scissors  for  fine  work,  a  catheter, 
sponges,  and  a  wooden  block  for  supporting  the  head.  A 
screw-driver  for  coffin  lids  may  also  on  occasions  be  found 
useful. 

Knives  should,  of  course,  be  sharp,  and  it  is  advisable  to 
have  the  means  of  sharpening  them  at  hand,  in  the  shape  of 
a  hone  and  oil.  With  a  little  practice  it  is  possible  to  put  a 
keen  edge  on  a  knife  in  a  very  few  minutes.  Instead  of  the 
finer  large  knives  sold  by  the  instrument-makers,  butcher's 
knives  will  do  admirably,  and  will  cost  a  fourth  or  fifth  of 
the  price. 

Another  necessary  item  in  the  pathologist's  equipment 
is  a  pair  of  scales  with  weights  from  one  gramme  to  five  kilos. 

Post-mortem  Table  and  Accessories. — The  post-mortem 
table  should  be  at  least  6  feet  long  and  2  feet  broad.  It 
should  be  either  a  solid  slate  slab  or  wood  covered  with  zinc. 
The  edge  should  be  raised,  and  runnels  arranged  so  that 
fluids  will  pass  to  a  central  waste-pipe  enclosed  in  an  iron 
pillar  supporting  the  table,  and  on  which  it  revolves.  There 
should  be  a  plentiful  supply  of  water ;  a  tap  overhead  with 
hose  attached ;  a  basin  with  hot  and  cold  supply  close  by 
for  washing  the  hands ;  a  large  sink  with  an  ordinary  tap, 
and  a  tap  with  rose  attached,  used  for  washing  organs,  the 
stream  from  which  can  be  easily  controlled  by  the  operator 
either  by  the  foot  or  elbow.  The  operator  should  frequently 
cleanse  his  gloves  under  running  water  to  prevent  blood, 
pus,  or  other  discharge  from  drying  on  them. 

It  is  useful  to  have  accessible  a  number  of  bottles  containing 
reagents  likely  to  be  required,  such  as  Gram's  iodine  for 
testing  for  waxy  disease  (see  p.  363),  dilute  hydrochloric  acid 
and  ferrocyanide  of  potassium  for  testing  for  hsemosiderin 
in  the  organs  (see  p.  353),  10  per  cent  formalin,  and  other 
fixatives  for  tissues,  and  a  supply  of  empty  bottles  with 
corks. 


THE  EQUIPMENT  OF  THE  PATHOLOGIST       9 

A  Bunsen  burner,  a  platinum  needle,  a  piece  of  metal  for 
searing  the  surface  of  organs,  slides,  and  culture  media  should 
be  close  at  hand.  A  number  of  large  sponges  will  be  found 
very  useful  for  mopping  out  cavities,  also  a  glass  measure  and 
a  syringe  and  trocars  for  injecting  specimens  with  preserva- 
tives. A  large  jar  of  Pick's  or  other  fixative  should  be  at 
hand  for  this  purpose,  and  pots  of  various  sizes  for  containing 
specimens. 

The  post-mortem  room  of  a  hospital  should  be  in  a  detached 
building.  The  room  itself  should  be  airy  and  well  lighted. 
It  should  communicate  with  a  preparation  room,  and  a 
laboratory  for  microscopic  and  bacteriological  work. 

The  operator  should,  of  course,  wear  a  clean  overall  to 
protect  his  clothing.  A  waterproof  apron  over  or  under 
this  is  advisable.  A  pair  of  spectacles  for  the  protection  of 
the  eyes  is  a  good  thing. 

Note-taking. — Previous  to  the  performance  of  the  sectio, 
<a  short  resume  of  the  main  clinical  features  of  the  case  should 
be  sent  to  the  pathologist.  Notes  dictated  by  the  operator 
during  the  sectio  should  be  taken  by  a  competent  person. 
This  is  absolutely  necessary,  as  the  more  minute  points  in 
the  case  cannot  be  put  down  unless  the  organs  are  actually 
before  the  operator.  Organs  change  considerably  in  colour 
even  during  the  course  of  the  sectio,  so  that  it  is  not  safe  to 
trust  to  the  description  of  a  case  written  up  afterwards, 
even  when  the  more  important  organs  are  preserved. 

Post-mortems  in  Private. — In  carrying  out  a  post- 
mortem in  private,  the  body  should  be  placed  on  a  kitchen 
table,  with  an  old  sheet  and  newspapers,  or,  if  possible, 
a  waterproof  sheet,  underneath.  Sometimes  the  bed  is  the 
only  place  available,  in  which  case  the  waterproof  is  very 
necessary.  The  head  should  be  supported  with  a  brick,  a 
block  of  wood,  or  a  suitable  box  wrapped  in  newspaper.  A 
slop-pail  and  basins,  with  a  plentiful  supply  of  water,  should 


io     THE  EQUIPMENT  OF  THE  PATHOLOGIST 

be  procured.  To  mask  unpleasant  odours,  a  piece  of  twisted 
brown  paper  lit  at  one  end,  the  other  end  being  thrust  into 
a  jug  and  left  to  smoulder,  or  a  handful  of  ground  coffee 
thrown  on  a  shovelful  of  burning  coals  will  be  found  useful. 
In  private,  if  the  spinal  cord  has  to  be  examined,  it  is  well 
to  begin  with  that.  A  number  of  newspapers,  bottles  for 
specimens,  sponges,  soap  and  towels  should  not  be  forgotten. 

Rules  to  be  observed  in  examining  Organs. — A  few 
simple  rules  should  be  borne  in  mind  when  examining  an 
organ.  It  is  well  to  have  some  definite  method  in  order  that 
nothing  be  passed  over.  The  student  should  remember,  in 
the  first  place,  to  look  before  touching,  the  former  being  much 
the  more  important  process.  Note  in  the  first  instance  the 
size  of  the  organ,  and  mentally  compare  it  with  what,  in 
your  experience,  is  the  normal  size,  remembering  always 
that  the  age  of  the  subject  from  which  the  specimen  was 
taken  is  an  important  item  in  drawing  a  conclusion  as  to 
size.  The  general  form  of  the  organ  should  next  be  examined, 
and  any  deviation  from  the  normal  noted,  such  as  swellings 
or  shrinking.  Examine  next  the  surface  of  the  organ, 
looking  for  exudate,  which,  if  recent,  is  friable  and  readily 
scraped  away;  if  organised,  it  is  stringy  and  difficult  to 
remove.  Opaque,  white,  pearly  areas  indicate  chronic 
inflammation.  Cicatrices  with  indrawing  or  puckering  of 
the  surface  indicate  old  infarcts  or  healed  tuberculous  or 
syphilitic  lesions.  A  finer  roughening,  giving  the  appearance 
of  morocco  leather,  is  always  indicative  of  fibrosis  in  the 
organ. 

Next,  the  organ  should  be  incised,  and  in  doing  so  some 
idea  of  its  consistence  may  be  arrived  at.  An  organ  which  is 
the  seat  of  fibrosis  will  be  tougher  and  more  difficult  to  cut. 
In  incising  an  organ  it  is  usual  to  do  so  from  the  rounded 
outer  and  broader  surface  towards  the  root  or  hilum  where 
the  vessels  enter  and  the  ducts  leave. 


THE  EQUIPMENT  OF  THE  PATHOLOGIST     n 

The  cut  edge  is  another  point  to  which  attention  should  be 
directed,  and  which  bears  upon  the  question  of  consistence. 
A  rounded  edge  after  a  cut  indicates  soft  consistence,  and 
is  associated  with  cloudy  swelling  and  fatty  change ;  a  sharp 
edge  is  found  when  the  organ  is  firm.  That  is  the  reason  for 
the  existence  of  a  sharp  edge  in  organs  the  seat  of  amyloid 
disease — the  waxy  material  gives  consistency  and  firmness 
to  the  tissue,  unless  complicated  by  other  degenerative 
conditions,  such  as  fatty  change. 

The  student  is  apt  to  consider  that  in  diseased  conditions 
associated  with  fatty  change,  a  greasy  feel  is  imparted  to  the 
organ.  As  a  matter  of  fact,  adipose  tissue  and  fat  generally 
is  greasy  to  the  touch,  but  it  is  only  comparatively  rarely 
that  fatty  change  (when  the  change  is  actually  a  degenerative 
one  in  the  parenchymatous  cells)  gives  to  the  organs  which 
are  the  seat  of  the  change  a  greasy  sensation  when  touched. 

The  next  step  is  to  examine  the  cut  surface.  The  colour 
and  any  irregularity  in  the  distribution  of  the  colouring 
should  be  noticed.  The  presence  of  bands  of  fibrous  tissue, 
pigmentations  of  various  kinds,  opaque  spots.  Grey,  trans- 
lucent areas  indicate  waxy  disease  or  accumulations  of  cells, 
such  as  tubercle  foci  and  leukaemia.  Opaque  white  spots 
are  indicative  of  degenerative  and  necrotic  foci,  such  as  areas 
of  focal  necrosis  in  the  liver  in  typhoid,  eclampsia,  etc.  Note 
also  the  condition  of  the  vessels  of  the  organ.  If  they  stand 
out  prominently,  it  is  an  indication  that  their  walls  are 
thickened.  Their  contents  should  also  be  noted,  whether 
that  is  fluid  or  solid,  and  the  character  of  the  clot  if  present. 
The  presence  of  gas  in  the  blood  should  be  looked  for. 

Use  of  Knife  in  making  Incisions. — In  incising  an  organ, 
the  way  in  which  the  knife  is  used  is  a  matter  of  no  little 
importance.  The  knife  should,  in  the  first  place,  be  a  large 
one,  considerably  larger  than  the  organ  itself ;  the  larger  the 
better.  It  must,  further,  be  a  sharp  knife.  As  regards  the 


12      THE  EQUIPMENT  OF  THE  PATHOLOGIST 

character  of  the  cut,  the  knife  should  be  drawn  along  and  not 
pressed  into  the  substance  of  the  organ.  The  cut  made  by 
drawing  the  knife  leaves  a  smooth  surface,  that  made  by 
pressing  the  knife  leaves  a  rough  surface.  Further,  the  cuts 
must  be  large  and  sweeping,  not  a  to-and-fro  movement 
which  will  leave  a  series  of  ridges.  If  possible,  the  whole 
cut  should  be  carried  out  in  a  single  sweep.  As  Virchow  was 
accustomed  to  say  to  his  students,  "  Smooth,  though  wrong, 
incisions  are  better  than  correct  and  uneven  ones." 


CHAPTER  III 

METHOD   OF  PROCEDURE 

Object  of  Post-mortem  Examination. — The  object  of  a 
post-mortem  examination  is  twofold — first,  the  discovery 
of  the  disease  condition  which  has  led  to  a  fatal  termination 
in  the  particular  case  in  point ;  second,  the  investigation,  as 
minutely  as  possible,  of  that  disease  condition  with  a  view 
to  advancing  medical  science  in  general. 

The  first  object  may  in  some  cases  be  attained  by  the 
most  cursory  examination  limited  to  a  single  organ  or 
part;  in  other  cases  only  the  closest  attention  to  detail 
and  the  investigation  of  the  apparently  insignificant  will 
be  followed  by  success ;  the  second  object  can  only  be 
attained  after  every  system  has  been  examined  with  the 
greatest  care  and  after  minute  investigation,  assisted  by  the 
microscope,  and,  it  may  be,  by  the  chemical  laboratory.  It 
follows  from  this  that  wherever  possible  a  detailed  examina- 
tion should  be  carried  out.  There  are  cases  where  the 
cursory  investigation  will  give  all  the  information  required, 
but  in  a  large  proportion  of  cases  the  pathologist  is  not  doing 
his  duty  unless  the  more  detailed  examination  be  resorted  to, 
that  is,  provided  always  permission  for  the  extended  sectio 
be  obtained  and  the  time  and  apparatus  be  available. 

Necessity  for  definite  Plan  of  Operation. — In    order 
13 


14  METHOD  OF  PROCEDURE 

to  carry  out  this  detailed  examination  some  definite  plan  of 
operation  is  necessary.  In  other  words,  before  starting  to 
carry  out  the  autopsy  it  is  quite  essential  that  the  operator 
should  have  some  idea  of  how  he  is  going  to  proceed  :  of  the 
order  in  which  he  is  going  to  examine  the  -various  body 
cavities  and  their  contents.  It  is  by  no  means  necessary 
to  adhere  to  the  same  plan  invariably.  In  fact,  the  experi- 
enced pathologist  will  alter  his  routine  frequently,  accord- 
ing to  the  indications  given  him  by  the  clinical  history 
as  to  the  parts  actually  diseased.  At  the  same  time  it  is 
advisable  to  have  some  definite  plan,  some  order  in  which 
the  various  parts  are  to  be  examined,  so  that  no  detail  may 
be  omitted. 

It  is  generally  stated  that  it  is  better .  to  begin  when 
possible  with  the  head,  as  otherwise  blood  may  escape  from 
the  vessels  of  the  head  while  the  thorax  is  being  examined, 
and  so  appearances  be  altered.  This  is  not  a  very  strong 
argument.  Virchow  long  ago  emphasised  the  necessity  of 
opening  the  abdominal  cavity,  before  the  thoracic,  in  order 
that  the  true  position  of  the  diaphragm  might  be  ascertained. 
As  a  matter  of  fact  this  is  usually  done,  but  not  for  that 
reason.  As  a  rule,  after  making  an  examination  of  the 
organs  in  situ  and  of  the  large  serous  sacs — pleura,  peri- 
cardium, peritoneum — one  begins  with  the  more  detailed 
examination  first  of  the  thoracic  organs. 

Different  Methods  of  Procedure. — As  Letulle  points 
out,  there  are  really  two  parts  in  a  complete  autopsy,  (i)  The 
examination  of  the  cerebro-spinal  system.  (2)  The  examina- 
tion of  the  viscera.  One  might  add  as  a  third  part  the 
examination  of  bones,  muscles,  vessels,  and  nerves.  But 
having  admitted  that  this  division  exists,  it  should  be  realised 
that  the  further  examination  of  these  parts,  more  particularly 
in  the  case  of  the  viscera,  must  be  carried  out  in  continuity. 
That  is  to  say,  taking,  for  example,  the  vascular  system, 


METHOD  OF  PROCEDURE  15 

heart,  arteries,  and  veins  should  be  examined  before  cutting 
through  any  large  vessel.  *  The  alimentary  system  should  be 
exposed  and  inspected  from  pharynx  to  rectum  before  it  is 
divided  into  sections ;  more  than  that,  the  various  canals, 
such  as  bile  and  pancreatic  ducts,  must  be  examined  while 
they  are  in  continuity  with  the  alimentary  tract.  This  is 
the  ideal  method,  and  it  is  the  method  advocated  and  carried 
out  by  Le tulle  and  others.  The  whole  of  the  thoracic  and 
abdominal  viscera  are  removed  and  examined  first  in  con- 
tinuity, arid  then  the  various  organs  removed  and  examined 
by  themselves.  In  practice,  however,  this  method  is  some- 
what tedious,  and  cannot  in  many  instances  be  carried  -out, 
owing  to  leave  being  obtained  for  the  examination  only  of 
certain  parts  of  the  body. 

Two  great  rules  emphasised  by  Orth  should  always  be 
kept  in  view.  The  first  is  that  a  part  should  never  be  removed 
from  its  position  before  its  relationship  to  its  surroundings 
has  been  established.  Thus  the  heart  should  never  be 
removed  for  examination  before  the  contents  of  the  pulmonary 
artery  and  its  larger  branches  have  been  investigated. 
Secondly,  no  part  should  be  taken  away  if  the  removal  of  it 
will  interfere  with  the  investigation  later  on  of  other  parts. 

To  sum  up,  it  is  well  for  the  pathologist  to  have  some 
routine  to  which  he  is  accustomed,  thus  avoiding  the  danger 
of  omissions,  but  this  plan  may  be  modified  according  to 

the  exigencies  of  the  case. 

• 

Surface  Examination. — First  there  comes  the  examina- 
tion of  the  body,  before  any  incision  is  made.  The  following 
points  should  be  attended  to  : — 

Development  of  the  Body. — Height,  breadth,  etc.,  presence 
or  absence  of  deformities.  Any  alterations  in  the  shape  of 
the  chest  should  be  particularly  noted ;  the  barrel-shaped 
chest  of  bronchitis  and  emphysema,  the  pigeon  breast  indica- 
tive of  rickets  in  early  life  are  two-  common  malformations. 


16  METHOD  OF  PROCEDURE 

Nutrition. — Whether  the  body  is  well  nourished,  poorly 
nourished,  or  emaciated. 

Age  and  Sex. 

Presence  and  degree  of  rigor  mortis.  This  is  observed 
first  in  the  muscles  of  the  face,  and  spreads  from  above 
downwards,  passing  off  in  the  same  order.  The  time  of  onset 
of  rigor  mortis  varies  according  to  the  time  which  has  elapsed 
since  death  and  according  to  the  cause  of  death.  In  cases  of 
sudden  death  due  to  injury  of  the  spinal  cord,  in  tetanus,  in 
strychnine  poisoning,  and  in  wasting  diseases,  such  as  tuber- 
culosis and  cancer,  the  condition  may  come  on  very  early. 
As  a  rule  it  appears  in  from  three  to  six  hours  after  death. 
Usually  the  condition  begins  to  pass  off  in  twenty-four 
to  forty-eight  hours,  the  time  depending  upon  the  cause  of 
death  and  the  conditions  under  which  the  body  is  kept.  In 
septic  conditions  and  in  warm  weather  rigor  mortis  passes 
off  rapidly. 

Alteration  in  Colour. — Pallor.  Any  deepening  of  the  normal 
colour  of  the  skin  or  the  presence  of  jaundice. 

Lividity. — This  naturally  occurs  after  death,  owing  to  the 
accumulation  of  blood  in  the  dependent  parts.  Post-mortem 
lividity  is  thus  most  marked  in  dependent  parts.  Where  lips 
or  face  are  livid,  some  abnormality  in  the  circulation  or 
death  from  suffocation  may  be  suspected.  Lividity  may 
also  be  due  to  bruising.  Such  livid  patches,  when  pressed 
upon,  remain  of  the  same  colour,  unlike  post-mortem  lividity, 
which  can  be  pressed  away.  When  bruised  parts  are  cut 
into,  the  blood  is  found  diffused  through  the  tissues.  A 
livid  colour  along  the  lines  of  the  superficial  vessels  may  be 
due  to  the  advance  of  decomposition,  owing  to  the  diffusion 
of  the  blood-colouring  matter  into  the  surrounding  tissues. 
Green  coloration,  an  indication  of  the  onset  of  decomposition, 
should  also  be  noted.  It  appears  first  over  the  abdomen 
and  in  the  spaces  between  the  lower  ribs. 

Skin    eruptions,    superficial    tumours,    scars,    or    recent 


METHOD  OF  PROCEDURE  17 

wounds  should  be  carefully  noted,  and  their  extent  esti- 
mated. 

Note  the  presence  of  oedema  and  its  distribution. 

Examine  the  various  orifices  of  the  body — mouth,  nose, 
ears — for  discharges,  foreign  bodies,  etc.  Note  the  condition 
of  the  teeth.  Examine  for  the  presence  of 'inguinal  or  femoral 
hernia.  Note  the  condition  of  the  external  genitals. 

Primary  Incision. — Standing  on  the  right  side  of  the 
body,  the  pathologist  grasps  his  knife  firmly  with  the  right 
hand  (Fig.  i).  The  incision  is  commenced  either  immedi- 
ately under  the  chin,  at  the  thyroid  cartilage,  or  just  above 
the  manubrium  sterni  in  the  middle  line.  It  is  carried 
downwards  through  skin  and  subcutaneous  tissue  to  left  of 
the  umbilicus,  as  far  as  the  symphysis  pubis.  Any  cicatrices 
or  recent  incisions  should  be  avoided.  Care  must  be  taken 
not  to  go  too  deeply  when  incising  the  abdomen,  in  order  to 
avoid  cutting  the  liver  or  bowel.  At  one  point,  usually  in  the 
epigastric  region,  the  incision  is  carried  through  muscle  and 
peritoneum  into  the  cavity.  The  index  and  middle  finger 
of  the  left  hand  are  then  inserted  into  the  opening,  and 
separated  so  as  to  put  the  tissue  on  stretch  (Fig.  i).  With 
the  knife  the  incision  is  prolonged,  the  two  fingers  following 
down,  to  the  pubes.  To  obtain  more  room,  the  rectus  muscle 
on  either  side  should  be  cut  transversely  through  immediately 
above  the  pubic  bone  without  injuring  the  skin. 

In  cases  where  permission  is  obtained  only  for  the 
examination  of  a  part  of  the  body — e.g.  thorax  or  abdomen 
— the  incision  should  be  correspondingly  limited. 

Reflection  of  Skin  and  Muscles. — The  next  step  in  the 
process  is  the  dissection  of  the  skin  and  muscles  of  the  chest 
from  sternum,  cartilages,  and  ribs,  and,  at  the  same  time,  of  the 
skin  of  the  neck  from  the  subjacent  tissue.  This  should  be 
done  by  grasping  the  skin,  etc.,  with  the  left  hand  and  steadily 
pulling  away  from  the  sternum  or  ribs.  The  areolar  tissue 


i8  METHOD  OF  PROCEDURE 

and  muscles  are  then  touched  here  and  there  with  the  edge 
of  the  knife  as  they  are  put  upon  the  stretch  (Fig.  2).  At 
this  stage  the  operator  will  be  in  a  position  to  determine  the 
amount  of  subcutaneous  fat,  also  the  appearance  of  the  muscles, 
which  in  wasting  diseases  are  often  abnormally  dark  and  dry, 
and  in  toxic  conditions  such  as  typhoid  fever  may  show  (more 
especially  the  recti  abdominales)  translucent,  glassy-looking 
areas — the  so-called  vitreus  degeneration  of  Zenker.  Also 
at  this  stage  the  mammcz  may  be  incised  through  the  pectoral 
muscles  and  examined  for  growths,  etc.  The  ribs  should  also 
be  examined  for  fractures  and  enlargement  of  the  costo- 
chondral  junctions  (rickety  rosary). 

Removal  of  Sternum. — Before  opening  the  thoracic 
cavity  the  level  of  the  diaphragm  may  be  noted.  Note  also 
the  level  of  the  lower  border  of  the  liver,  and  the  position 
of  the  stomach  and  other  viscera,  as  regards  the  lower  costal 
margin.  Then,  commencing  at  the  second  costal  cartilage 
close  to  its  attachment  to  the  rib,  and  cutting  obliquely 
outwards,  so  as  to  avoid  injuring  the  underlying  lung,  one 
divides  the  cartilages  on  either  side. 

In  many  cases  of  muscular,  and  more  particularly  of  old 
men,  it  will  be  found  impossible  to  do  this  with  a  knife.  The 
saw  should  then  be  used,  and  the  cartilages  severed,  holding 
the  saw  perpendicularly  to  the  ribs.  Great  care  should  be 
taken  not  to  splinter  the  ribs  in  any  way,  so  to  avoid  puncture 
wounds  of  the  hands  in  subsequent  manipulations.  An 
excellent  way  of  avoiding  such  wounds  is  to  fold  the  skin 
which  has  been  dissected  from  sternum  and  ribs  in  over  the 
severed  ends  of  the  ribs. 

The  sterno-clavicular  joint  on  either  side  should  then  be 
disarticulated  by  inserting  the  point  of  the  knife  perpendicu- 
larly (Fig.  3),  the  knife  being  afterwards  turned  edge  out- 
wards, the  incision  prolonged  between  clavicle  and  first  rib 
for  half  an  inch,  and  the  rib  cartilage  divided  external  to  the 


METHOD  OF  PROCEDURE  19 

point  of  disarticulation.  If  the  cartilage  of  the  first  rib  is 
ossified  it  will  be  necessary  to  use  a  pair  of  bone  forceps  or 
a  saw  to  divide  it. 

The  sternum  and  cartilages  should  then  be  removed  from 
below  upwards,  the  diaphragmatic  attachment  being,  in  the 
first  instance,  cut  through.  If  the  sternum  be  firmly  adherent 
to  the  mediastinal  tissues,  great  care  should  be  taken  not 
to  damage  aneurysm  or  tumour,  to  which  this  adherence  may 
be  due. 

Serous  Sacs. — The  removal  of  the  sternum  opens  both 
pleural  cavities,  and  at  this  stage  of  the  proceedings  the 
serous  sacs — peritoneum,  pleurse,  and  pericardium — should 
be  examined.  The  pericardium  is  opened  by  two  incisions, 
commencing  at  the  lower  corner  on  the  right  side  and  ex- 
tending, the  one  upwards  to  the  aorta,  the  other  outwards  to 
the  apex  of  the  heart.  In  cases  where  air  embolism  is  sus- 
pected the  pericardial  sac  should  be  filled  with  water,  and  the 
right  ventricle  punctured  and  pressed,  when,  if  air  be  present 
in  the  right  side  of  the  heart,  bubbles  will  appear. 

The  general  aspect  of  the  thoracic  contents  should  at  this 
point  be  noted.  The  size  of  the  heart  and  the  extent  to 
which  it  is  overlapped  by  the  lungs  are  points  of  importance. 

In  examining  the  serous  sacs  look  for  the  presence  of  fluid 
in  excess  •  note  its  colour,  whether  it  is  clear  or  turbid  or 
blood-stained.  Examine  the  surfaces  of  the  viscera.  These 
ought  to  be  shiny  and  perfectly  smooth.  Any  dimming  of 
the  surfaces  indicates  inflammatory  exudate.  Where  there 
are  indications  of  such  exudate,  films  and  cultures  should  be 
made  from  the  fluid  with  all  necessary  precautions.  Where 
pus  or  fcecal  matter  is  present  in  the  abdomen)  careful  search 
should  be  made  for  perforation  of  the  viscera,  more  particularly 
the  vermiform  appendix,  the  lower  end  of  the  ileum,  the 
stomach,  and  the  duodenum.  A  careful  examination  should 
also  be  made  of  the  surface  of  the  viscera  for  any  thickening 


20  METHOD  OF  PROCEDURE 

or  adhesions,  indicative  of  ulcerations  or  tumour  formations 
within. 

When  blood  or  blood  clot  is  present  in  the  abdomen,  search 
should  be  made  for  a  ruptured  organ,  viscus,  or  vessel.  An 
area  with  adherent  blood  clot  is  often  an  indication  of  the 
source  of  the  haemorrhage. 

Examine  for  adhesions  between  visceral  and  parietal  layers 
of  pleura,  and  note  the  degree  of  force  required  to  break  down 
these  adhesions. 

At  this  stage,  both  lungs  should  be  freed  from  any  abnormal 
attachment.  If  there  are  extensive  adhesions  which  cannot 
readily  be  broken  down,  an  incision  should  be  made  through 
the  parietal  pleura,  and  the  latter  by  means  of  the  fingers 
torn  from  the  ribs. 

Procedure  for  removing  Contents  of  Thoracic  and 
Abdominal  Cavities. — Having  examined  the  serous  sacs, 
the  next  step  is  to  remove  and  examine  the  contents  of  the 
thoracic  and  abdominal  cavities.  The  way  in  which  this  is 
done  will  be  determined  not  infrequently  by  the  nature  of 
the  case,  the  pathologist  being  guided  by  the  summary  of 
the  clinical  history,  or  whatever  information  is  available. 
To  put  the  matter  shortly,  there  are  two  main  methods  of 
procedure  :  (i)  to  remove  the  organs  one  by  one  and  examine 
them  separate  from  their  surroundings  ;  (2)  to  remove  the 
contents  of  the  cavities  entire  or  in  groups,  afterwards  to 
examine  canals,  vessels,  ducts,  etc.,  in  continuity  with  the 
viscera,  and  then,  and  only  then,  to  sever  attachments  and 
remove  and  examine  the  organs  themselves.  Unquestionably 
the  latter  is  the  proper  method.  If  the  former  be  adopted, 
although  in  many  cases  no  harm  will  be  done,  in  some  in- 
stances points  will  be  missed  and  valuable  specimens  be 
ruined.  The  experienced  pathologist  can,  as  a  rule,  decide 
whether  he  may  risk  adopting  the  first  method,  but  the 
tyro  ought,  if  it  is  at  all  possible,  to  make  use  of  the 


METHOD  OF  PROCEDURE  21 

second.  But  even  if  one  decide  for  the  second  method, 
certain  options  present  themselves.  One  may  remove  the 
whole  contents  of  both  cavities  together  as  Letulle  does, 
but,  as  already  indicated,  this  has  its  disadvantages.  One 
may  compromise  matters  somewhat  and  adopt  the  method 
advocated  by  Shennan,  which  is  excellent,  but  which  necessi- 
tates postponing  the  removal  of  the  thoracic  contents  (the 
most  important  organs  in  the  majority  of  cases)  until  all  the 
abdominal  organs  have  been  removed. 

The  method  recommended  by  the  author  is  the  removal,  in 
the  first  instance,  of  the  thoracic  contents  entire,  the  examination 
of  the  vessels,  etc.,  in  continuity,  then  the  separation  of  the 
organs  and  their  investigation  separately.  Subsequently  one 
deals  with  the  abdomen,  from  which  the  organs  are  removed, 
not  en  masse,  but  in  groups.  This  should  be  the  routine 
method.  It  has  certain  disadvantages  :  oesophagus,  aorta, 
vena  cava,  and  thoracic  duct  will  be  cut  through.  But, 
as  regards  the  first,  the  cases  in  which  it  is  advisable  to 
preserve  the  continuity  of  oesophagus  with  stomach — tumours 
of  oesophagus,  cases  of  poisoning,  cases  of  severe  hsematemesis 
from  varicose  veins — are  comparatively  rare,  easily  recognised, 
and  special  methods  can  be  adopted  for  the  preservation  of 
the  continuity.  As  regards  aorta,  there  is  no  great  dis- 
advantage in  examining  it  in  two  sections.  And  as  regards 
the  thoracic  duct,  it  is  only  very  rarely  (as  in  cases  of  acute 
miliary  tuberculosis)  that  it  is  advisable  to  dissect  it  out  and 
investigate  it  in  its  entire  length. 

(1)  Removal  of  the  Organs  one  by  one. — Nothing  special 
need  be  said  about  the  method  of  procedure  in  this  case. 
It  is  usual  to  begin  with  the  heart,  then  the  lungs,  spleen, 
liver,   kidneys,   etc.     In   many   cases   the   pathologist   will 
begin  with  the  organ  believed  to  be  mainly  affected.    As 
far  as  possible  Orth's  rules  (p.  15)  should  be  carried  out. 

(2)  Method  of  examining  the  Thoracic  and  Abdominal  Con- 
tents by  removing  them  in  Groups : — 


22  METHOD  OF  PROCEDURE 


EXAMINATION  OF  THE  THORACIC  CONTENTS 

If  not  originally  begun  below  the  chin,  the  primary  skin 
incision  should  be  carried  upwards  to  that  point.  In  many 
cases  this  may  not  be  necessary,  the  trachea  being  cut  through 
at  some  point  above  the  level  of  the  clavicles.  But  in  some 
cases  it  is  necessary  to  have  tongue  and  pharynx  attached  to 
trachea.  The  skin  and  sterno-mastoid  muscles  are  dissected 
away  from  the  structures  in  the  neck  and  beneath  the  chin. 
The  knife  is  then  passed  upwards  through  the  floor  of  the 
mouth  below  the  symphysis  menti,  and  by  sweeping  it  round 
on  either  side,  keeping  close  to  the  rami  of  the  lower  jaw,  the 
attachments  of  the  muscles  are  cut  through  (Fig.  4).  The 
tongue  can  then  be  pulled  through  the  opening,  and  by  drawing 
upon  it  a  view  of  the  pharynx  can  be  obtained.  The  attach- 
ment of  soft  to  hard  palate  can  then  be  cut  through ;  the 
posterior  wall  of  the  pharynx  is  incised  and  dissected  down. 
Care  should  be  taken  to  include  both  tonsils  in  the  structures 
removed.  Further  traction  upon  the  tongue  will  then  enable 
the  operator  to  tear  through  the  loose  cellular  tissue  attaching 
the  oesophagus  to  the  prevertebral  fascia.  At  some  point 
the  carotids  are  cut  through,  also  the  subclavian  vessels. 
While  all  this  is  being  done,  attention  should  be  paid  to 
any  enlarged  glands,  ihrombosed  veins,  etc.,  which  may  be  met 
with. 

The  lungs  having  been  at  an  earlier  stage  freed  from 
adhesions,  a  few  touches  of  the  knife  will  enable  the 
operator,  by  traction  on  the  trachea  in  a  downward  direction, 
to  detach  the  thoracic  contents  from  the  prevertebral 
fascia  as  far  down  as  the  diaphragm.  The  oesophagus  is 
then  ligatured  to  prevent  the  escape  of  stomach  contents. 
The  oesophagus,  aorta,  and  attachment  of  pericardium 
to  diaphragm  are  next  cut  through  and  the  thoracic 


METHOD  OF  PROCEDURE  23 

viscera  are  removed   and   placed   upon  a  table  or  in  the 
sink. 

When  it  is  desired  to  preserve  the  continuity  of  the 
oesophagus  with  stomach,  and  of  the  thoracic  duct  and  aorta, 
then  the  whole  of  the  body  contents  (thoracic  and  abdominal) 
should  be  removed  together,  as  in  Letulle's  method. 

(Esophagus  and  Trachea. — The  thoracic  contents  are 
now  placed,  anterior  aspect  downwards,  on  the  table  or  sink. 
The  oesophagus  is  slit  open  with  a  pair  of  bowel  scissors. 
The  trachea  and  bronchi  are  opened  in  a  similar  manner.  If 
it  is  desired  to  preserve  the  oesophagus,  it  can  be  first  removed 
or  turned  to  the  left  side.  After  opening  the  air  passages, 
the  nature  of  the  contents  of  bronchi  and  trachea  are  noted. 

Aorta. — In  the  same  way  the  aorta  is  slit  up  and  examined 
as  far  round  as  the  ascending  portion.  If  it  be  extensively 
diseased,  its  continuity  with  the  heart  should  be  preserved. 
The  organs  should  then  be  placed  anterior  aspect  upwards, 
and  attention  should  in  the  first  place  be  directed  to  the 
heart. 

Pulmonary  Artery.  —  Incise  the  pulmonary  artery 
longitudinally,  and  examine  carefully  for  the  presence  of 
thrombi,  following  the  branches  going  to  the  two  lungs  as 
far  as  possible.  Very  commonly  post-mortem  or  agonal 
clots  are  present,  but  these  are  readily  distinguished  from 
thrombi  (see  p.  63). 

Superior  Vena  Cava. — The  superior  vena  cava  should 
then  be  opened  as  far  as  the  right  auricle.  The  incision  is 
afterwards  carried  down  to  the  inferior  vena  cava. 

Heart. — The  heart  is  now  separated  from  the  two  lungs. 
For  this  purpose  it  is  advisable  to  get  an  assistant  to  steady 
the  other  viscera.  The  organ  is  pulled  upwards  and  over 
towards  the  right  lung,  and  the  pulmonary  veins  are  cut 
through  as  they  enter  the  left  auricle.  After  this  the  pul- 


24  METHOD  OF  PROCEDURE 

monary  artery  and  aorta  are  severed.  In  cases  where  the 
latter  is  diseased  it  may  be  advisable,  as  already  stated,  to 
preserve  its  continuity  with  the  heart.  To  do  this,  a  little 
further  dissection  is  necessary,  the  aorta  being  separated 
from  the  surrounding  structures. 

Surface  of  Heart. — The  heart  is  now  taken  in  the  hand 
and  a  more  careful  examination  of  the  surface  made.  Note 
should  be  taken  of  its  shape  and  size,  of  any  areas  of  thickened 
pericardium  (milk  spots),  small  haemorrhages ,  fibrinous 
exudate.  The  amount  of  subpericar dial  fat  should  also  be 
noted. 

Right  Auricle. — Then,  attention  being  turned  in  the  first 
place  to  the  right  auricle,  an  incision  is  made  from  the  centre 
of  the  previous  one  joining  the  two  venae  cavse  into  the 
auricular  appendix,  search  being  made  for  thrombi. 

Eight  Ventricle.  —  Passing  the  forefinger  of  the  left 
hand  through  the  tricuspid  valve  into  the  right  ventricle 
and  grasping  the  wall  between  the  ringer  and  thumb,  incise 
the  wall  of  the  right  ventricle  by  means  of  a  probe-pointed 
bistoury,  commencing  just  below  the  pulmonary  artery  and 
carrying  the  incision  down  parallel  to  the  interventricular 
septum  and  half  an  inch  to  the  left  of  it  (Fig.  5). 

Tricuspid  Valve. — Now  test  the  size  of  the  tricuspid  valve 
either  by  means  of  a  suitable  cone  or  with  the  fingers,  the 
normal  orifice  admitting  three  digits.  The  segments  of  the 
valve  should  then  be  examined.  This  can  be  done  quite 
easily  from  the  auricular  aspect.  One  of  the  segments, 
the  largest  as  a  rule,  is  situated  anteriorly  and  slightly  to 
the  left.  It  separates  the  orifice  of  the  valve  from  the 
infundibulum  or  conus  arteriosus}  and  is  therefore  known  as 
infundibular  segment.  The  second  is  situated  to  the  right, 
corresponding  to  the  free  margin  of  the  ventricle ;  the  third 
lies  internally  and  posteriorly  against  the  ventricular  septum, 
and  is  known  as  the  septal  segment. 


METHOD  OF  PROCEDURE  25 

Pulmonary  Valve.  —  The  competence  of  the  pulmonary 
valve  is  now  tested  by  allowing  a  stream  of  water  to  fall  from 
a  height  into  the  cut  end,  the  sides  of  the  vessel  being  sup- 
ported (Fig.  8).  The  primary  incision  into  the  ventricle  is 
then  prolonged  upwards  into  the  artery,  care  being  taken 
to  cut  between  the  right  and  left  anterior  segments.  Examine 
the  segments  for  thickening  or  vegetations.  Before  leaving 
the  right  side  of  the  heart  examine  the  thickness  of  the  muscle 
of  the  right  ventricle.  Note  the  amount  of  fat  lying  over  it, 
and  particularly  if  there  is  any  infiltration  of  the  fat  into  the 
muscle. 

Left  Auricle.  —  Open  the  left  auricle  by  an  incision 
joining  the  two  upper  pulmonary  veins.  Continue  the  incision 
so  as  to  open  the  auricular  appendix  in  its  entire  length 
(Fig.  5).  Examine  the  interior  of  the  auricle  for  thrombi, 
vegetations,  and  thickening  of  the  endocardium. 

Mitral  Valve. — A  longitudinal  incision  is  now  made 
into  the  wall  of  the  left  ventricle,  somewhat  anterior  to  the 
left  border  (Fig.  5).  The  mitral  valve  is  inspected  from  above 
and  its  diameter  measured.  This  may  be  done  roughly  by 
the  fingers,  the  valve  admitting  two  digits.  Run  the  knife 
through  the  valve  and  out  at  the  opening  in  the  wall  of  the 
ventricle  and  cut  outwards.  The  segments  of  the  valve  are 
arranged,  the  larger  in  front  and  to  the  right,  between  the 
auricular  and  aortic  openings,  the  smaller  to  the  left  and 
behind,  so  that,  if  done  properly,  the  cut  will  lie  between 
the  segments. 

Left  Ventricle.  —  Examine  the  valve  for  thickening, 
calcareous  deposits,  vegetations,  etc.,  also  the  chordce  tendinece 
for  thickening,  shortening,  vegetations,  or  rupture.  Note  the 
appearance  of  the  papillary  muscles,  incising  them  and 
examining  for fibrous  change.  Note  the  colour  and  appearance 
of  the  muscle  generally,  looking  tor  fatty  and  fibrous  changes. 
Examine  more  particularly  the  state  of  the  muscle  towards 


26  METHOD  OF  PROCEDURE 

the  apex  of  the  ventricle  where  interstitial  myocarditis  is 
usually  found.  Incise  the  interventricular  septum,  looking 
for  interstitial  change.  Measure  the  breadth  of  the  wall  of 
the  ventricle  and  test  the  consistence  of  the  muscle. 

Aortic  Valve. — Turn  next  to  the  aortic  valve.  A  good 
way  of  exposing  this  valve  is  to  run  the  probe-pointed  bistoury 
successively  into  the  two  coronary  arteries,  and  then  to  cut 
upwards  and  outwards  (Fig.  7),  thus  slitting  up  the  aorta 
on  either  side,  and  at  the  same  time  the  commencement  of 
the  two  coronary  arteries.  Test  the  competence  of  the  aortic 
valve  by  a  stream  of  water  poured  in  from  above  (Fig.  8) ; 
examine  the  condition  of  the  segments  (there  are  three — an 
anterior  and  a  right  and  left  posterior)  and  measure  the 
circumference. 

Coronary  Arteries. — Next  examine  carefully  the  condi- 
tion of  the  two  coronary  arteries,  opening  up  their  various 
branches  by  slitting  with  knife  or  scissors,  or,  in  the  case  of 
the  finer  ones,  by  cutting  them  across.  This  should  be  done 
most  carefully  in  cases  of  sudden  death,  search  being  made 
for  impacted  emboli  or  thrombi  on  atheromatous  patches.  If 
required,  the  aortic  valve  may  be  exposed  more  fully  by 
cutting  between  the  anterior  and  the  left  posterior  segment 
downwards  through  the  anterior  wall  of  the  left  ventricle 
until  the  lateral  cut  in  the  ventricular  wall  is  reached. 

Certain  anatomical  points  regarding  the  coronary  arteries 
and  their  distribution  should  be  remembered.  The  right 
vessel,  which  arises  from  the  anterior  sinus  of  Valsalva,  is 
usually  smaller  than  the  left ;  it  supplies  the  greater  part  of 
the  wall  of  the  right  ventricle,  the  right  auricle,  and  the 
greater  portion  of  the  left  auricle.  The  left  coronary  artery, 
which  arises  from  the  left  posterior  sinus  of  Valsalva,  soon 
after  its  commencement  divides  into  two  branches.  It 
supplies  the  outer  wall  of  the  left  ventricle  and  the  anterior 
two-thirds  of  the  septum  ventriculorum,  a  small  part  of  the 


METHOD  OF  PROCEDURE  27 

right  ventricle  near  the  septum  anteriorly,  and  the  inferior 
portion  of  the  left  auricle.  The  more  important  of  the  two 
divisions  of  the  left  coronary  is  the  descending  branch  which 
passes  down  the  anterior  inter  ventricular  groove.  This 
branch  is  the  one  most  frequently  the  seat  of  atheromatous 
change.  It  supplies  the  apex  of  the  left  ventricle  and  the 
septum  as  well  as  the  anterior  wall  and  papillary  muscles. 
Hence  it  is  in  these  positions  that  chronic  interstitial  myo- 
carditis is  most  frequently  met  with. 

Lungs. — The  lungs  should  now  be  separated  from  the 
mediastinal  tissues  by  cutting  through  their  roots. 

Pleural  Surface. — Examine,  in  the  first  instance,  the 
pleural  surfaces,  looking  for  petechial  hemorrhages,  fibrinous 
exudate,  fibrous  thickening,  puckering,  and  cicatrisation,  more 
particularly  at  the  apices.  Note  the  colour  of  the  organs, 
especially  at  the  posterior  and  the  lower  parts.  Note  also 
the  consistence ;  feel  for  any  solid  areas  or  points  at  apex 
and  along  borders.  Next  cut  into  the  organs  by  a  perpendicu- 
lar incision  directed  from  above  downwards,  and  from  its 
outer,  rounded,  thick  border  towards  its  inner,  anterior  sharp 
border  (Fig.  6).  Other  cuts  should  be  made  from  the  original 
incision  forwards  to  the  anterior  border  in  the  case  of  each 
lobe. 

Cut  Surface  of  Lungs. — On  the  cut  surface,  note  in  the 
first  place  alterations  in  colour,  the  presence  of  cavities,  areas 
of  caseation,  etc.  Next  feel  the  lung  substance  and  squeeze  it, 
looking  for  the  presence  or  absence  of  air  bubbles  or  for  the 
presence  of  fluid  ;  note  the  colour  and  appearance  of  the  fluid 
expressed.  Examine  carefully  all  solid  areas,  and  determine 
whether  the  solidity  is  due  to  some  exudate  filling  the  air 
cells  or  to  interstitial  fibrous  change.  Suspected  solid  areas 
should  be  placed  in  a  glass  beaker  of  water.  Consolidated 
areas  sink  in  water. 


28  METHOD  OF  PROCEDURE 

Bronchi. — Next  open  up  the  bronchi  with  the  probe- 
pointed  bistoury  and  note  the  appearance  of  any  fluid  they 
contain ;  also  the  appearance  of  their  walls.  Open  up  the 
branches  of  the  pulmonary  artery  similarly,  looking  for  thrombi 
or  emboli.  Incise  the  bronchial  glands,  noting  the  degree  of 
pigmentation)  the  presence  of  caseous  areas  or  of  calcification. 

Lastly,  the  thyroid,  parathyroid,  and  thymus  glands 
should  be,  examined,  also  the  remaining  mediastinal  tissue. 

Thyroid  Gland. — The  thyroid  gland  should  be  examined 
as  regards  its  size.  Longitudinal  incisions  are  made  into  its 
substance  and  the  cut  surface  examined  for  colloid  material, 
the  presence  of  cysts,  etc. 

Parathyroid  Glands.  —  The  average  number  of  para- 
thyroids is  four.  They  are  found  in  close  proximity  with 
the  thyroid  gland,  usually  posteriorly.  They  are  minute, 
oval,  pink  bodies,  averaging  from  6  to  8  mm.  in  length. 

Thymus  Gland. — The  thymus  gland  is  situated  partly 
in  the  neck,  partly  in  the  mediastinum  immediately  behind 
the  manubrium  sterni.  It  is  largest  during  the  second  year 
of  life  (}  oz.  or  20-25  gm.).  Until  puberty  it  remains  large, 
thereafter  undergoing  atrophy,  until  about  the  twenty-fifth 
year  it  has  practically  disappeared.  Occasionally  it  may 
persist  throughout  life.  An  abnormally  large  thymus  gland 
has  been  found  in  certain  cases  of  sudden  death,  particularly 
in  young  children. 

EXAMINATION  OF  THE  ABDOMINAL  CONTENTS 

Removal  of  Intestines. — The  first  step  in  this  procedure 
is  to  remove  the  intestines,  small  and  large.  The  actual 
examination  of  these  should  be  deferred  to  the  last  moment, 
in  order  to  avoid  the  odour  of  faecal  matter.  Before  cutting 
through  the  mesentery  search  should  be  made  for  any  enlarged 


METHOD  OF  PROCEDURE  29 

glands,  more  particularly  caseous  or  calcareous  glands,  and 
the  relationship  of  these  glands  to  the  bowel  established. 
Next  look  for  the  duodeno-jejunal  junction,  and  having  cut 
through  the  mesentery  at  that  point,  place  two  ligatures  round 
the  bowel  and  divide  it  between  them.  Place  a  ligature  also 
round  the  lower  end  of  the  rectum  and  cut  it  through  as  low  down 
as  possible.  Next  cut  through  the  mesentery,  close  to  the  bowel, 
from  the  jejunum  to  ileo-csecal  valve.  This  is  easily  done  by 
pulling  upon  the  bowel  with  the  left  hand  and  merely  touching 
the  mesentery  with  the  knife,  which,  however,  cannot  be 
too  sharp  for  the  purpose.  The  knife  should  be  held  with  its 
blade  perpendicular  to  the  bowel  (see  Fig.  9). 

Having  freed  the  bowel  as  far  as  the  cczcum,  the  latter 
should  be  removed  from  its  attachments,  along  with  the  ascending 
colon  and  appendix.  The  transverse  colon  should  next  be 
detached  from  the  stomach  and  removed  with  the  splenic 
flexure,  descending  and  pelvic  colon.  In  this  way  the  whole 
of  the  bowel  from  jejunum  to  rectum  can  be  examined  in 
continuity.  As  previously  stated,  it  is  well  to  defer  opening 
it  to  a  late  stage  in  the  post-mortem  examination. 

Method  of  opening  Bowel. — The  bowel  is  opened  by 
means  of  a  pair  of  bowel  or  other  probe-pointed,  sharp-edged 
scissors,  along  its  mesenteric  attachment  in  the  case  of  the 
small,  along  one  of  the  longitudinal  muscular  bands  in  the  case 
of  the  large  intestine  (Fig.  10).  The  colour  and  general 
appearance  of  the  contents  should,  at  the  same  time,  be 
noted. 

Examination  of  Intestine.  —  Having  opened  the  gut, 
take  it  up,  piece  by  piece,  commencing  with  its  upper  end, 
and  wash  it  carefully  under  a  gentle  stream  of  water.  More 
particular  attention  should  be  paid  to  the  lower  end  of  the 
ileum,  where  typhoid  and  tuberculous  ulcerations  are  specially 
found,  and  to  the  large  bowel  generally.  Look  for  increase 
of  vascularity,  ulcerations,  tumours,  animal  parasites. 


3o  METHOD  OF  PROCEDURE 

Vermiform  Appendix. — The  appendix  has  been  looked 
at  during  the  preliminary  investigation  of  the  abdominal 
cavity.  It  should  now  be  more  carefully  examined. 

It  should  always  be  remembered  in  connection  with  the 
intestinal  canal  that  post-mortem  changes  are  most  marked 
in  the  hollow  viscera,  and  that  these  changes  tend  to  mask  the 
appearances  in  pathological  conditions.  Black  and  greenish- 
black  coloration  of  the  bowel  and  neighbouring  organs  is 
common,  and  is  due  to  the  action  of  the  sulphuretted  hydrogen 
gas  from  the  gut  upon  the  iron  pigment  of  the  blood. 

Removal  of  Liver,  etc. — In  the  next  place,  the  liver ,  with 
the  stomachy  duodenum,  pancreas,  and  spleen,  should  be  removed 
without  disturbing  the  vascular  and  duct  connections  of  these 
organs.  This  can  best  be  done  by  standing,  in  the  first 
instance,  on  the  left  side  of  the  body,  pulling  upon  the  liver 
with  the  left  hand  and  cutting  through  its  connections  with 
diaphragm  and  posterior  abdominal  wall.  Care  should  be 
taken  at  the  start  to  leave  intact  the  right  suprarenal  gland, 
which  is  in  close  contact  with  the  liver.  The  duodenum  is 
then  detached  by  cutting  through  its  peritoneal  covering. 
The  liver  is  then  pulled  still  further  over  to  the  left  side  of 
the  body,  and  its  connection  with  the  large  vessels  and 
retroperitoneal  tissue  cut  through.  Standing  on  the  right 
side  of  the  body,  the  cardiac  end  of  the  stomach  is  cut  through, 
the  spleen  detached  all  but  its  vascular  connections,  the  tail 
of  the  pancreas  dissected  away  from  left  suprarenal,  the  left 
lobe  of  the  liver  freed  from  the  diaphragm,  and  the  whole 
group  of  viscera  lifted  out.  It  is  more  particularly  in  remov- 
ing the  intestines  and  other  abdominal  viscera  that  an 
assistant  is  desirable. 

Stomach  and  Duodenum. — Having  placed  this  group 
of  viscera  in  the  sink  or  on  the  table  near  it,  the  first  procedure 
is  to  open  the  stomach  and  duodenum.  This  is  usually 


METHOD  OF  PROCEDURE  31 

done  by  cutting  with  the  scissors  along  the  greater  curvature  of 
the  stomach  and  along  the  anterior  wall  of  the  duodenum. 
Of  all  organs,  the  stomach  is  the  one  which  suffers  most  from 
post-mortem  changes,  so  that  a  great  deal  of  what  appears  to 
be  abnormal  in  the  stomach  must  be  discounted.  Look 
more  especially  for  ulcers  and  tumours  towards  the  pyloric 
end  of  the  stomach,  and  in  the  first  part  of  the  duodenum. 
Press  upon  the  gall  bladder  to  see  if  bile  can  readily  be  made 
to  flow  along  the  common  duct  into  the  duodenum. 

Bile  and  Pancreatic  Ducts.  —  Incise  the  common  bile 
duct  and  pancreatic  duct,  pass  a  probe  along  them,  and  if 
necessary  open  them  up. 

Gall  Bladder.  —  Open  the  gall  bladder  and  note  its 
contents,  the  colour  and  consistence  of  the  bile,  and  any  gall 
stones  which  may  be  present.  Ascertain  whether  the  cystic 
duct  is  patent  by  passing  a  probe  along  it. 

Liver. — Attention  should  next  be  turned  upon  the  liver. 
In  removing  that  organ,  any  adhesions  between  it  and  the 
pariet,es  will  have  been  noted.  Any  exudate  on  the  surface 
of  the  organ,  thickenings  of  the  capsule,  cicatrices,  etc.,  should 
be  searched  for.  The  size  of  the  organ  should  be  noted,  also 
any  alteration  in  shape,  the  presence  of  perpendicular  or 
horizontal  sulci,  such  as  are  caused  by  tight  lacing  and  the 
wearing  of  tight  belts. 

OUTER  SURFACE. — Note  whether  the  surface  is  smooth  or 
rough,  also  the  colour  of  the  organ  and  any  irregularity  in 
colouring.  Incise  the  organ  by  means  of  a  number  of  cuts  in 
a  perpendicular  direction.  Note  the  character  of  the  cut  edge, 
whether  rounded  or  sharp. 

CUT  SURFACE.  —  Examine  carefully  the  cut  surfaces, 
noting  colour,  the  outline  of  the  lobules,  irregularities  in  colour, 
etc.  Next  test  the  consistence  of  the  liver  substance  by 
pushing  the  finger  into  it. 


32  METHOD  OF  PROCEDURE 

Pancreas. — The  pancreas  is  best  examined  further  by 
a  series  of  transverse  cuts.  The  fat  in  the  neighbourhood 
of  the  organ  should  be  examined  for  areas  of  fat  necrosis. 

The  portal  and  splenic  veins  should  then  be  opened  up  and 
search  made  for  thrombi.  The  lymph  glands  in  the  neighbour- 
hood of  the  head  of  the  pancreas  should  also  be  examined. 

Spleen. — The  spleen,  which  may  be  removed  by  itself 
or  along  with  stomach  and  liver,  should  be  weighed,  its  size 
noted,  also  any  roughening  of  its  surface  or  thickening  of  its 
capsule,  also  irregularities  in  colour  indicating  infarcts.  Its 
consistence  should  be  noted,  and  the  organ  opened  by  a  longi- 
tudinal incision  from  its  outer  surface  to  its  hilum.  On  the 
cut  surface  the  general  colour,  the  appearance  of  the  Malpighian 
bodies,  should  they  be  visible,  and  the  existence  of  any  tubercle 
nodules  or  other  opaque  areas  should  be  noted. 

All  the  organs  have  now  been  removed  from  the  abdomen 
with  the  exception  of  the  kidneys,  the  pelvic  organs,  and  the 
large  vessels. 

Removal  of  Kidneys  with  Bladder. — Note  the  position 
of  the  kidneys  and  the  courses  of  the  ureters.  The  kidneys 
and  suprarenals  should  be  removed  together.  Where  the 
existence  of  renal  and  bladder  conditions  is  suspected,  it  is  well 
to  remove  kidneys,  ureters,  and  bladder  together.  This  can  be 
done  by  cutting  through  the  blood-vessels  of  the  kidneys 
and  dissecting  down  the  ureters  to  the  brim  of  the  pelvis. 
A  cut  is  now  made  through  peritoneum  round  the  brim  of 
the  pelvis,  down  to  the  bone,  and  by  means  of  the  fingers 
the  bladder,  pelvic  colon,  and,  in  the  female,  the  genital 
organs  are  all  separated  from  their  attachments  to  the 
parietes,  the  vessels,  etc.  being  cut  through  close  to  the  bone. 
Grasp  these  organs  with  the  left  hand,  pull  them  upwards 
and  backwards,  and  cut  through  the  urethra.  The  point 
of  the  knife  is  then  pushed  down  through  the  skin  of  the 
perineum  close  to  the  anus.  A  circular  cut  is  made  round 


METHOD  OF  PROCEDURE  33 

the  anal  orifice  and  the  group  of  organs  is  removed  and  placed 
in  the  sink. 

In  the  case  of  the  male,  when  it  is  desired  to  retain  the 
continuity  between  bladder  and  urethra,  as  in  prostatic  disease, 
cases  of  rupture  of  the  urethra  from  fracture  of  the  pelvis, 
etc.,  a  special  method  of  procedure  should  be  adopted.  The 
pelvic  contents  are  freed  from  the  bony  wall  as  before.  The 
original  abdominal  incision  is  then  carried  downwards  for  an 
inch  or  so  along  the  penis.  The  penis  is  then  cut  through. 
After  freeing  the  pubic  bones  from  skin  and  muscular  attach- 
ments the  two  rami  are  sawn  through  on  either  side.  A  little 
further  dissection  will  enable  the  operator  to  remove  the 
whole  pelvic  contents  with  the  symphysis  pubis  and  root  of 
penis. 

If  it  be  desired  to  remove  the  female  genital  organs  with 
bladder  and  rectum,  a  cut  is  made  all  round  the  brim  of  the 
pelvis  through  the  peritoneum  ;  this  is  separated  as  above  by 
means  of  the  fingers  from  the  walls  of  the  pelvis,  the  knife 
being  used  occasionally  to  divide  vessels  and  nerves.  The 
point  of  the  knife  is  next  pushed  down  through  the  skin  at 
one  side  of  the  perineum  and,  by  an  elliptical  cut,  the  whole 
floor  of  the  pelvis,  including  vulva  and  anus,  is  cut  out.  The 
pelvic  organs  can  now  be  lifted  out  from  above. 

Suprarenals. — Examine  the  two  suprarenals  by  detaching 
them  from  the  kidneys  and  making  a  series  of  transverse 
incisions. 

Bladder. — The  bladder  may  now  be  opened  by  inserting 
the  probe-pointed  bistoury  into  the  urethra  and  cutting 
upwards  to  the  fundus.  Note  any  enlargements  of  the  prostate) 
ulcer ations  of  the  mucous  membrane }  stone  in  the  bladder,  etc. 
Examine  the  ureters,  and  if  necessary  slit  them  up. 

If  there  is  no  obvious  reason  for  keeping  the  kidneys 
attached,  the  ureters  are  severed  at  their  commencement 
and  the  kidneys  weighed. 

The  kidneys  may  be  removed  by  themselves  either  after  the 
removal  of  the  intestines,  or,  in  cases  where  it  is  not  considered 

3 


34  METHOD  OF  PROCEDURE 

necessary  to  examine  these,  before  the  other  viscera  are 
touched.  This  is  done  by  making  a  cut  through  the  peri- 
toneum and  fascia,  inserting  the  fingers,  stripping  the  organ 
from  its  surroundings  and  pulling  it  forward.  The  vessels 
and  ureter  are  then  cut  through. 

Kidneys. — Note  in  the  first  place  the  size  of  the  organs. 
Examine  the  surface  for  irregularities  and  cysts,  the  more 
obvious  irregularities  of  persistent  fcetal  lobulation  or  old 
infarction,  or  the  finer  markings  due  to  chronic  interstitial 
nephritis.  Next  incise  the  organ  by  cutting  with  the  large  knife 
from  the  outer  border  to  the  hilum  (Fig.  13) ;  in  doing  so,  note 
the  consistence  of  the  organ.  Examine  the  cortex,  noting  its 
colour,  its  width,  comparing  it  with  that  of  the  medulla. 
Look  for  the  glomeruli,  which  may  be  seen  as  dark  red 
spots.  Note  any  opaque  lines  or  patches  indicating  fatty 
degeneration  in  the  tubules.  Look  at  the  large  vessels 
between  cortex  and  medulla,  and  note  any  tortuosity  of 
the  interlobular  vessels  which  run  upwards  from  them  into 
the  cortex.  Lastly,  note  the  amount  of  fat  which  is  present 
between  the  kidney  substance  and  the  pelvis  (peripelvic  fat) 
and  examine  the  pelvis  itself. 

Then,  taking  the  kidney  in  the  right  hand,  grasp  the  capsule 
of  the  organ  with  a  pair  of  dissecting  forceps  and  strip  it 
backwards.  In  a  normal  kidney  this  can  be  done  quite 
easily,  and  the  surface  displayed  is  perfectly  smooth.  If  the 
capsule  is  thickened  and  adherent,  or  if  the  surface  is  rough, 
the  presence  of  chronic  interstitial  nephritis  is  certain.  The 
appearance  of  the  small  cysts,  so  frequently  found  under  the 
capsule  under  similar  conditions,  should  also  be  noted.  Note 
also  whether  small  veins  (venae  stellatse)  under  the  capsule 
are  unduly  prominent. 

Uterus  and  Appendages. — The  uterus  is  examined  by 
making  an  incision  into  it  from  fundus  to  cervix,  and  trans- 
verse incisions  along  the  upper  border,  so  as  to  display  the 


METHOD  OF  PROCEDURE  35 

openings  of  the  Fallopian  tubes.    The  ovaries  are  incised 
in  their  longest  diameter. 

Testicles.  —  The  testicles  may  be  examined  without 
injuring  the  scrotum  by  incising  the  tissues  at  the  external 
abdominal  ring  and  pressing  the  testicle  upwards.  The 
gland  is  opened  by  an  incision  in  its  longest  diameter. 

Thoracic  Duct,  etc. — There  only  remain  now  for  examina- 
tion the  large  vessels,  the  thoracic  duct,  the  retroperitoneal 
glands,  and  the  cosliac  ganglia.  The  inferior  vena  cava, 
aorta,  and  their  branches  are  slit  with  scissors  along  their 
anterior  walls  and  search  made  for  thrombi  and  emboli. 

The  thoracic  duct  will  be  found  behind  and  to  the  right 
of  the  aorta.  In  the  thorax  it  lies  to  the  right  between  the 
aorta  and  the  azygos  vein.  It  should  be  examined  more 
especially  in  cases  of  miliary  tuberculosis,  and  its  relation  to 
any  caseous  lymph  gland  investigated. 

The  semilunar  ganglia  will  be  found  on  the  aorta  around 
the  cceliac  axis. 


EXAMINATION  OF   THE  BEAIN 

Scalp  Incision. — Place  a  block  under  the  nape  of  the 
neck  to  support  the  head.  Insert  a  small  knife  with  its 
back  to  the  skull  under  the  skin  immediately  behind  the 
right  ear,  cut  upwards  and  outwards  to  the  vertex,  and  from 
the  vertex  in  the  same  manner  down  to  a  corresponding 
point  behind  the  left  ear.  It  is  advisable  to  cut  outwards 
in  this  way  in  order  that  the  hair  may  not  be  cut  off.  It  is 
well  also,  in  the  case  of  women,  to  separate  the  hair  along 
the  line  of  the  incision,  throwing  part  forwards  and  the  other 
part  backwards.  Raise  a  portion  of  the  scalp  by  means  of 
the  hair  and  cut  below  it  with  the  knife.  Then  grasp  the 
portion  of  scalp  freed  with  the  left  hand,  and,  pulling  forwards 


36  METHOD  OF  PROCEDURE 

or  backwards  as  the  case  may  be,  put  the  tissues  joining 
scalp  to  skull  and  temporal  muscle  on  the  stretch,  rendering 
the  cutting  of  them  more  easy.  This  should  be  done  forward, 
nearly  to  the  supraciliary  ridges,  and  backwards  to  below 
the  occipital  protuberance.  In  carrying  this  out,  note  the 
presence  of  any  extravasation  of  blood  below  the  scalp  and 
examine  the  surface  of  the  skull  for  fracture. 

Saw-Cuts. — Next,  by  means  of  an  old  knife,  mark  out 
the  line  along  which  the  bone  is  to  be  sawn  through.  In 
front,  this  line  should  run  below  the  frontal  eminences,  and 
be  carried  back  on  either  side,  cutting  through  the  temporal 
muscles  to  a  point  just  above  and  behind  the  ears.  Another 
cut  starts  from  one  of  these  points,  and,  making  an  angle 
of  about  1 60°  with  the  former  cut,  runs  across  the  back  of 
the  skull  a  little  in  front  of  the  occipital  protuberance  to 
the  corresponding  point  on  the  other  side. 

Next,  standing  on  the  right  side  of  the  body,  take  a  dry 
towel  and  throw  it  over  the  skull,  place  the  left  hand  on  the 
towel  and  through  it  grasp  the  calvarium,  throwing  the 
anterior  portion  of  the  towel  over  the  back  of  the  hand. 
Take  the  saw  in  the  right  hand  and  commence  to  saw  through 
the  outer  table  of  the  frontal  bone,  following  the  previously 
mentioned  lines  as  closely  as  possible.  The  saw-cut  should 
be  carried  nearly,  but  not  quite,  through  the  inner  table,  in 
order  to  avoid  injuring  the  membranes  and  brain.  When 
a  fracture  is  suspected,  however,  it  is  well  to  carry  the  saw- 
cut  through  both  tables.  Then,  taking  the  hammer  and 
chisel,  insert  the  edge  of  the  latter  into  the  saw-cut,  and,  by 
a  series  of  sharp  taps,  crack  through  the  remainder  of  the 
inner  table.  It  is  well  to  tilt  the  chisel  slightly,  so  that  the 
angle  of  the  instrument  enters  first. 

Eemoval  of  Calvarium. — The  next  step  is  to  pull  back 
the  calvarium  by  means  of  the  hook  on  the  cross-piece  of 
the  chisel,  at  the  same  time  separating  the  dura  from  the 


METHOD  OF  PROCEDURE  37 

bone  with  such  an  instrument  as  a  periosteum  separator. 
In  the  case  of  old  people,  alcoholics,  and  also  young  children 
the  dura  may  be  found  too  firmly  adherent  to  the  bone  for 
this.  In  such  a  case  the  dura  should  be  divided  all  along 
the  saw  cut  and  removed  at  the  same  time  as  the  calvarium. 
Incise  the  superior  longitudinal  sinus  and  examine  for  clots 
or  thrombi. 

m  Dura  Mater. — With  a  pair  of  dissecting  forceps  pick 
up  a  portion  of  the  dura  mater  anteriorly  and  incise  it. 
Insert  a  probe-pointed  bistoury  into  the  opening  and  cut 
round  the  dura  on  both  sides,  at  the  level  at  which  the  skull 
was  sawn  through.  Insert  the  knife  between  the  left  frontal 
lobe  and  the  falx  cerebri,  with  the  edge  towards  the  falx. 
Cut  through  the  latter  and  pull  back  the  dura  mater.  The 
dura  will  usually  be  found  adherent  over  the  vertex  by 
means  of  vessels  and  Pacchionian  bodies. 

Brain  Surface. — Examine  the  exposed  surface  of  the 
brain,  noting  its  vascularity,  any  flattening  of  the  convolutions, 
or  filling  up  of  the  sulci  with  exudate  or  blood. 

Removal  of  Brain. — Insert  two  fingers  of  the  left  hand 
under  each  frontal  lobe  and  gently  pull  the  brain  back. 
Detach  the  olfactory  bulbs  from  the  cribriform  plate  with  the 
handle  of  the  knife.  Cut  through  the  optic  nerves  and  the 
internal  carotid  vessels  as  near  the  bone  as  possible.  Cut 
through  the  3rd,  4th,  5th,  6th,  and  yth  nerves.  Cut  the 
tentorium  cerebelli  along  its  attachment  to  the  petrous 
portion  of  the  temporal  on  either  side  (Fig.  n).  Divide  the 
8th  and  Qth  nerves.  Pass  the  bistoury  down  the  cord  and 
divide  it  obliquely  as  low  down  as  possible.  Sever  the  two 
vertebral  arteries  and  a  few  nerve  roots  and  the  brain  will 
tilt  back  into  the  left  hand. 

Cerebro-spinal  Fluid. — During  ail  this  process,  cerebro- 
spinal  fluid  will  escape.  Note  the  amount  and  character  of 


38  METHOD  OF  PROCEDURE 

this  fluid,  whether  clear  or  opaque,  and,  if  necessary,  secure 
a  specimen  for  further  examination. 

Base  of  Skull. — Either  before  or  after  the  examination 
of  the  brain,  the  base  of  the  skull  should  be  further  investi- 
gated. The  lateral  and  other  venous  sinuses  should  be  slit 
open  and  their  contents  examined.  Where  fracture  is  sus- 
pected, strip  off  the  dura  mater  from  the  bones  by  means 
of  dissecting  forceps.  • 

Examination  of  Brain. — The  brain  should  now  be 
weighed  and  its  surf  ace  further  examined.  Note  the  condition 
of  the  vessels,  more  particularly  those  at  the  base,  looking 
for  opaque  areas  of  atheroma,  thrombi,  or  small  aneurysms. 
Note  thickening  or  opacity  of  the  pia-arachnoid.  Examine 
for  exudate  in  the  subarachnoid  space,  more  particularly 
at  the  base  of  the  brain.  Examine  the  Sylvian  fissures 
on  either  side  for  small  tubercles  along  the  lines  of  the 
vessels.  Pass  the  fingers  carefully  over  the  whole  surface 
of  the  organ,  noting  the  presence  of  any  area  of  exceptional 
softness. 

The  method  of  proceeding  further  with  the  examination 
of  the  brain  depends  to  a  great  extent  upon  the  patho- 
logical condition  present.  In  a  large  proportion  of  cases 
it  is  advisable  to  fix  the  organ  before  cutting  it  up.  This 
is  done  by  injecting  10  per  cent  formalin,  or  Pick's  or  some 
other  preservative,  into  the  larger  vessels  at  the  base,  placing 
the  whole  organ  in  similar  fluid,  padding  the  jar,  in  which 
it  is  suspended  by  means  of  a  piece  of  string  run  through  the 
basilar  artery  and  attached  to  the  lid  of  the  jar,  with  cotton 
wool,  and  leaving  it  there  for  some  days  at  least. 

Section  of  Brain. — When  it  is  necessary  at  once  to 
examine  the  whole  organ,  it  should  be  placed  vertex  down- 
wards and  the  pons  and  medulla  removed  by  cutting  through 
the  crura  cerebri.  The  cerebrum  is  then  placed  upon  its 


METHOD  OF  PROCEDURE  39 

base,  and  with  a  large  and  sharp  knife  a  series  of  horizontal 
sections  are  made  at  intervals  of  half  an  inch,  commencing 
at  the  vertex,  the  organ  being  steadied  by  means  of  the 
left  hand  placed  flat  upon  it.  The  pons  and  medulla  are 
then  opened  up  by  means  of  a  series  of  transverse  cuts  and 
the  cerebellum  examined  by  an  incision  from  its  posterior 
border  to  the  peduncles.  Search  is  then  made  on  the  cut 
surfaces  for  hcemorrhages ,  areas  of  softening,  tumours,  etc. 

EXAMINATION  OF  THE  SPINAL  CORD 

Removal  of  Spinal  Cord. — Turn  the  body  over  on  the 
face,  with  the  head  hanging  well  down  over  the  end  of  the 
table.  Make  an  incision  through  the  skin  over  the  spinous 
processes  from  the  occiput  to  the  sacrum.  Cut  the  muscles 
through  on  either  side  down  to  the  laminae,  pulling  aside  the 
muscles  from  the  spinous  processes.  Then  saw  through  the 
laminae  on  either  side  about  one  half-inch  from  the  middle 
line,  directing  the  edge  of  the  saw  slightly  inwards.  It  is 
unnecessary  to  saw  below  the  third  or  fourth  lumbar  vertebra, 
as  the  cord  does  not  reach  farther  than  the  second  lumbar. 
A  rough  guide  for  the  lower  end  is  the  crest  of  the  ilium. 

Having  partially  sawn  through  the  laminae,  complete  the 
process  with  the  hammer  and  chisel,  taking  care  not  to 
damage  the  cord.  Lift  up  the  spinous  processes  thus  set 
free  at  some  point,  and  then,  with  the  bone  forceps,  proceed 
to  bite  through  the  remainder  of  the  laminae  on  either  side, 
lifting  up  the  spinous  processes  as  you  proceed.  This  should 
be  done  above  as  high  as  the  atlas  and  below  as  far  as  the 
3rd  or  4th  lumbar.  Free  the  cord  at  the  lower  end  by 
cutting  through  the  nerve-roots  and  the  dura ;  then,  holding 
dura  and  cord,  cut  through  the  nerve-roots  upwards,  if 
necessary  removing  the  ganglia  with  the  roots. 

At  the  upper  end  of  the  cord  cut  through  the  dura  from 
above,  i.e.  through  the  foramen  magnum,  and  remove  the 


40  METHOD  OF  PROCEDURE 

whole  cord.  Next  lay  the  cord  on  a  flat  surface,  incise  the 
dura  anteriorly,  and  preserve  the  cord  in  the  first  instance  in 
10  per  cent  formalin.  After  two  or  three  days  make  a  series 
of  transverse  cuts,  dividing  the  cord  into  a  number  of  segments 
which  remain  attached  posteriorly  to  the  dura.  Subse- 
quently, thinner  portions  may  be  placed  in  Miiller's,  Marchi's, 
or  other  fixative. 

In  cases  where  it  is  desirable  to  retain  the  continuity 
between  brain  and  cord,  as  in  cases  of  lesions  of  the  cervical 
region,  the  cord  should  be  exposed  first  and  all  the  nerve- 
roots  severed.  The  dura  mater  of  the  upper  portion  of  the 
cord  is  cut  through  from  above,  also  the  upper  nerve-roots, 
and  if  desired  the  cord  at  the  level  of  the  foramen  magnum 
may  be  exposed  by  taking  a  wedge-shaped  piece  of  bone  from 
the  back  of  the  skull.  The  cord  will  now  come  away  with  the 
brain. 

Eye  and  Orbit. — The  eye  and  contents  of  the  orbit  may 
be  examined  by  chipping  through  the  orbital  plate  of  the 
frontal  and  removing  the  pieces  of  bone  with  a  pair  of  bone 
forceps  beginning  at  the  optic  foramen.  The  posterior  half 
of  the  eye  can  then  be  removed  by  making  an  equatorial  cut 
with  a  pair  of  sharp-pointed  scissors  without  damaging  the 
appearance  of  the  face. 

Middle  Ear. — The  middle  ear  and  mastoid  antrum  can 
be  readily  examined  after  stripping  the  dura  from  the  base 
of  the  skull,  by  chipping  off  the  upper  surface  of  the  petrous 
portion  of  the  temporal  bone  with  a  chisel,  or  by  merely 
opening  through  the  thin  tegmen  tympani.  For  more  careful 
examination  it  will  be  necessary  to  remove  the  petrous  portion 
of  the  temporal  entire  and  decalcify  it  in  bulk,  afterwards 
cutting  it  up  (Fig.  12). 

Other  Accessory  Cavities.— The  frontal,  ethmoidal  and 
sphenoidal  sinuses  can  be  opened  up  by  chipping  away 
portions  of  their  bony  walls  (Fig.  12). 


METHOD  OF  PROCEDURE  41 

Another  method  is,  after  stripping  the  dura,  to  make  a 
saw-cut  (Harke's)  through  the  base  of  the  skull  in  its 
sagittal  diameter  a  little  to  the  right  of  the  middle 
line  (Fig.  12),  care  having  been  taken  in  the  first  instance 
to  dissect  the  anterior  flap  of  skin  down  to  the  root  of  the 
nose,  the  posterior  well  down  behind  the  occiput.  In 
making  the  saw -cut  the  hard  palate  and  two  upper 
cervical  vertebrae  must  be  severed,  and  great  care  must 
be  taken  not  to  injure  the  external  surface  of  the  face. 
The  two  halves  of  the  skull  can  then  be  separated  and 
the  right  frontal  sinus,  the  ethmoidal  labyrinth,  and  the 
sphenoidal  sinus  examined.  The  nasal  cavities  can  be 
examined  at  the  same  time. 

In  all  cases  of  meningitis  careful  examination  should  be 
made  of  the  cavities  in  the  skull. 

The  maxillary  antrum  is  best  opened  by  lifting  the  upper 
lip,  dissecting  upwards  and  subsequently  chiselling  through 
the  bony  wall  of  the  cavity. 

Summary  of  Steps  in  Method  of  Procedure. 

1.  External  appearances. 

2.  Primary  incision,  reflection  of  skin  and  muscles,  removal 
of  sternum. 

3.  Examination    of    serous    sacs  —  pleurse,  pericardium, 
peritoneum. 

4.  Removal  of  contents  of  thoracic  cavity,  examination  of 

(a)  (Esophagus. 

(b)  Larynx  and  trachea. 

(c)  Aorta. 

(d)  Pulmonary  artery. 

(e)  Heart. 

CO  Lungs- 

(g)  Mediastinal  contents. 

5.  Ligature  of  intestine  at  junction  of  duodenum  and 
jejunum,  and  removal  of  whole  intestinal  tract. 


42  METHOD  OF  PROCEDURE 

6.  Removal  of  stomach  and  duodenum,  liver,  spleen  and 
pancreas,  and  examination  of  these  in  detail. 

7.  Removal    of    kidneys,   suprarenals,    ureters,   and,    if 
necessary,  of  the  bladder  in  continuity  with  these. 

8.  Removal   and    examination    of   pelvic    contents   and 
testicles. 

9.  Examination  of  abdominal  aorta,  etc. 

10.  Opening  up  skull,  removal  and  examination  of  brain. 

11.  Examination  of  base  of  skull  and  accessory  cavities. 

12.  Removal  of  spinal  cord. 

13.  Examination    of    peripheral    nerves,    bones,    joints, 
vessels,  etc. 

14.  Opening  and  examination  of  intestine. 


LETULLE'S  METHOD 

After  the  preliminary  incision  and  the  removal  of  the 
sternum,  the  floor  of  the  mouth  is  cut  through  close  to  the 
jaw,  and  the  tongue,  pharynx,  tonsils,  larynx,  oesophagus  are 
dissected  down  along  with  the  carotid  arteries,  jugular  veins, 
thyroid  and  lymphatic  glands.  The  pleurae  are  then  examined. 
Should  there  be  no  adhesions  present,  the  left  lung  is  drawn 
over,  the  operator  standing  on  the  right  side.  The  pleura  is 
then  cut  through  longitudinally  where  it  is  reflected  from  the 
vertebrae  on  to  the  lungs  and  mediastinal  contents.  The 
intercostal  arteries  are  then  cut  through  and  the  oesophagus 
and  other  contents  of  the  posterior  mediastinum  detached  from 
the  prevertebral  fascia  by  pulling  gently.  The  same  thing  is 
then  done  for  the  right  pleura,  the  operator  standing  on  the 
left  side,  care  being  taken  in  this  case  not  to  injure  the 
thoracic  duct  and  the  vena  azygos  major.  The  brachial  plexus 
and  the  subclavian  arteries  and  veins  are  then  cut  through  at 
the  inner  margin  of  the  first  rib,  and  the  whole  contents  of 
neck  and  thorax  are  free.  In  cases  where  there  are  extensive 
firm  adhesions  between  parietal  and  visceral  pleura  it  is 
necessary  to  tear  away  the  parietal  pleura  from  the  ribs  and 
intercostal  muscles  by  means  of  the  fingers.  The  attachments 


METHOD  OF  PROCEDURE  43 

of  the  diaphragm  are  then  cut  through,  taking  care  not  to 
injure  stomach  or  liver.  The  whole  of  the  parietal  peritoneum 
is  then  stripped,  along  with  the  abdominal  contents,  including 
kidneys,  vessels,  etc.,  leaving  only  the  psoas  muscles.  The 
iliac  vessels  are  cut  through  as  low  down  as  possible.  The 
peritoneum  is  stripped  from  the  sides  of  the  pelvis,  the  skin 
is  cut  through  round  the  anal  orifice,  and  the  whole  of  the 
viscera  removed  and  placed  upon  a  dissecting  table. 

The  examination  of  the  parts  in  detail  commences  by 
placing  the  viscera  with  their  posterior  aspect  upwards  and 
opening  the  venae  azygos  major  and  minor  and  the  thoracic 
duct.  The  suprarenal  glands  are  then  removed  and  examined. 
The  ureters  are  isolated  and  opened,  the  kidneys  removed  and 
examined.  The  aorta  and  the  inferior  vena  cava  are  then 
opened  throughout  their  length.  The  trunk  and  rootlets  of 
the  portal  vein  are  isolated  and  opened  up  and  the  common 
bile  duct  examined.  The  aorta  is  then  dissected  away  from 
other  structures  and  the  oesophagus  and  cardiac  end  of  the 
stomach  isolated.  The  tongue,  pharynx,  and  tonsils  are  then 
examined  and  the  oesophagus,  trachea,  and  bronchi  opened 
up.  The  vagus  and  other  nerves  and  the  lymph  glands 
of  the  neck  are  investigated.  The  viscera  being  turned  over, 
the  thymus  and  thyroid  glands  are  examined.  The  superior 
vena  cava  and  its  tributaries  are  then  opened.  Next,  the 
pericardium  is  opened,  and  the  first  part  of  the  aorta,  the 
pulmonary  artery  and  veins  and  their  branches  outside  the 
lungs  are  opened  up.  The  heart  is  next  examined  externally 
and  removed  from  its  attachments.  The  lungs  are  also 
detached  and  examined.  After  examination  of  the  diaphragm, 
the  liver  and  its  bile  passages  are  investigated  and  detached, 
also  the  spleen.  Next,  the  stomach,  pancreas,  and  duodenum 
are  isolated  and,  along  with  the  oesophagus,  removed,  opened 
up,  and  examined.  The  intestinal  canal  is  then  examined 
from  the  outside,  detached,  opened,  and  investigated  in  its 
various  sections.  The  examination  finishes  with  the  genital 
organs  and  urinary  bladder. 


SHENNAN'S  METHOD 
The  organs  are  removed  in  the  following  order : — 


44  METHOD  OF  PROCEDURE 

(1)  Small  intestine, — with  or  without — 

(2)  Large  intestine. 

(3)  Stomach  and  duodenum,  with  liver,  bile  ducts  through- 
out their  whole  length,  pancreas,  spleen,  and  mesentery. 

(4)  Kidneys  with  suprarenals  and  ureters. 

(5)  Thoracic     contents     along     with     the     cervical     soft 
structures,  the  aorta  in  its  whole  length,  inferior  -vena  cava, 
crura  of  the  diaphragm  with  solar  plexus  and  receptaculum 
chyli. 

(6)  Pelvic  organs,  which  in  certain  cases  may  be  removed 
in  continuity  with  large  intestine,  and  kidneys. 

Stitching  up  Incisions.  Toilet  of  the  Body.— After  the 
completion  of  the  examination  it  is  absolutely  essential  that 
the  body  be  restored  as  nearly  as  possible  to  its  original 
condition. 

In  the  first  place  all  fluid  should  be  got  rid  of  by  tilting 
the  body  or  by  swabbing  out  the  cavities  with  sponges. 
The  organs  are  then  replaced  and  sawdust,  wool,  tow, 
or  newspapers  used  to  compensate  for  the  loss  of  fluids, 
etc.  Firm  plugs  of  wool  are  then  placed  in  the  mouth, 
anus,  vagina,  etc.,  in  order  to  prevent  the  escape  of  any 
fluids. 

The  skin  incisions  are  closed  by  means  of  the  glover's  or 
blanket  stitch,  a  packing  needle  and  strong  twine  being  used. 
In  carrying  out  this  procedure  the  needle  is  always  passed 
from  within  outwards,  the  slack  of  the  twine  being  held 
firmly  between  the  fingers  of  the  left  hand  (Fig.  14).  The 
stitches  should  be  about  half  an  inch  apart. 

Finally,  all  trace  of  blood  is  removed  from  the  surface  of 
the  body  by  sponging. 

Cleansing  of  Gloves  and  Hands.— After  completing  all 
operations  in  which  the  hands  come  in  contact  with  the 
body  or  its  contents,  the  gloves,  while  still  on  the  hand, 
should  be  washed  in  cold  running  water,  at  first  without, 
then  with  soap.  Subsequently  they  are  washed  in  biniodide 


METHOD  OF  PROCEDURE  45 

of  mercury  spirit.  They  are  then  removed  from  the  hands, 
and  if  any  leakage  of  blood  or  other  fluid  has  occurred  the 
interior  should  be  treated  in  a  similar  fashion. 

The  hands  are  then  thoroughly  washed  with  soap  in  cold 
running  water. 


CHAPTER  IV 

DISEASES   OF  THE  HEART  AND   PERICARDIUM 

MALFORMATION  OF  THE  HEART  AND  GREAT 
VESSELS 

THE  heart  is  developed  in  the  first  instance  as  a  single  tube, 
with  primitive  auricle,  ventricle,  and  aortic  bulb.  The 
structure  later  becomes  bent  upon  itself  and  septa  appear 
in  all  three  divisions,  so  that  eventually  there  are  two  auricles, 
two  ventricles,  and  two  vessels — the  aorta  and  pulmonary 
artery.  The  commonest  congenital  malformations  of  the 
heart  are  associated  with  defects  in  the  formation  of  these 
septa. 

1.  Defective  Inter-auricular  Septum. — A  degree  of  this, 
i.e.  slight  patency  of  the  foramen  ovale,  is  a  very  common 
occurrence  (30-50  per  cent  of  cases).    In  the  vast  majority 
of  the  cases,  owing  to  the  smallness  of  the  aperture  and  to 
its  oblique  direction,  there  is  no  interference  with  the  function 
of  the  organ.    In  cases  of  stenosis  of  the  pulmonary  artery 
or  aorta,  however,  the  defect  in  the  septum  may  be  marked. 

2.  Defective   Interventricular    Septum. — The    separa- 
tion of  the  ventricle  into  two  begins  near  the  apex.    The 
septum  rises  towards  the  base.    The  last  portion  to  form 
is  the  portion  represented  by  the  "  undefended  spot  "  in  the 

46 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  47 

fully  developed  heart.  It  is  at  this  point  that  defects  in  the 
septum  most  commonly  occur.  As  in  the  case  of  defective 
interauricular  septum,  patency  is  usually  associated  with 
defects  in  the  vessels,  most  commonly  with  stenosis  of  the 
pulmonary  artery.  Complete  absence  of  the  septum  results 
in  the  so-called  three-chambered  heart. 

3.  Congenital    Stenosis   of  the   Pulmonary   Artery. — 

This  is  one  of  the  commonest  congenital  defects,  and  its 
existence  leads  to  a  number  of  others — defective  inter- 
auricular  and  interventricular  septa  and  patency  of  the 
ductus  arteriosus.  The  narrowing  may  occur  at  the  valves 
or  in  the  artery  beyond  the  valve.  The  cause  may  be  (i) 
malformation  of  the  septum  dividing  pulmonary  artery  from 
aorta,  the  septum  being  found  too  far  to  the  right.  (2)  Fcetal 
endocarditis.  All  degrees  of  the  condition  to  complete 
obliteration  or  atresia  may  be  found. 

4.  Congenital  Stenosis  of  the  Aorta. — This   is   much 
more  rare  than  the  preceding  condition.    Again,  it  may 
occur  at  the  valve  or  in  the  vessel  beyond.     When  it  occurs 
at  the  valve  there  is  usually  defect  of  the  septa  superadded. 
Stenosis  of  the  vessel  beyond,  owing  to  the  persistence  of  the 
ductus  arteriosus,  is  not  of  so  much  importance,  the  circulation 
being  carried  on  through  the  latter  vessel.    Stenosis  is  some- 
times caused  by  a  circular  fibrous  band  at  the  point  where 
the  ductus  arteriosus  joins  the  aorta. 

5.  Persistence  of  the  Ductus  Arteriosus,   or,  in  other 
words,  patency  in  extrauterine  life  of  the  communication 
between  the  pulmonary  artery  and  the  thoracic  aorta  accom- 
panies other  defects,  such  as  narrowing  of  the  pulmonary  or 
aortic  orifices. 

6.  Abnormalities  in  the  Valves.  —  These  mostly  occur 
in  the  semilunar  valves,     (a)  There  may  in  the  first  place  be 
complete  fusion  of  the  segments  leading  to  stenosis,     (b)  There 


48  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

may  be  only  two  cusps,  a  large  and  a  small  one,  the  larger  in 
some  cases  showing  evidence  of  partial  division  into  two. 
(c)  The  segments  may  be  abnormally  numerous.  There  may 
be  four  instead  of  three,  and  all  differing  in  size,  (d)  The 
segments  may  showfenestrations.  This  is  a  common  occurrence, 
but  as  the  openings  are  usually  close  to  the  free  margin,  and 
as  the  area  of  contact  of  the  segments  extends  some  distance 
from  the  free  margin,  there  is  no  incompetence  of  the  valve 
as  a  result. 

Of  congenital  anomalies  of  the  auriculo-ventricular  valves 
the  commonest  is  coalescence  oj  the  segments  oj  the  tricuspid 
valve.  This  may  be  due  to  fcetal  endocarditis.  It  leads  to 
patency  of  the  foramen  ovale. 

7.  Abnormalities  in  the  Great  Vessels. — There  may 
be  transposition  of  the  aorta  and  pulmonary  artery,  so  that 
the  latter  takes  origin  from  the  left  ventricle,  the  former 
from  the  right.  Occasionally  a  double  aorta  is  met  with — a 
condition  found  normally  in  reptiles.  Or  the  aorta  may  pass 
to  the  right,  the  condition  found  in  birds. 

The  heart  may  be  situated  to  the  right  side  of  the  body.  This 
may  or  may  not  be  associated  with  transposition  of  the  other 
viscera.  Occasionally  the  pericardial  sac  is  absent  and  the 
heart  may  be  situated  in  the  abdomen  (ectopia  cordis). 


DISEASES  OF  THE  PERICARDIUM 

Under  the  term  pericardium  are  included  (i)  the  sac 
formed  of  fibrous  tissue,  triangular  in  shape,  whose  base  rests 
upon  the  diaphragm,  and  whose  sides  are  attached  to  the 
pleurae  laterally,  the  lower  portion  of  the  sternum  anteriorly, 
and  the  mediastinum  posteriorly  ;  (2)  the  serous  endothelial 
lining  of  this  (parietal  pericardium)  which  is  reflected  on  to 
the  surface  of  the  heart  (visceral  pericardium  or  epicardium), 
and  (3)  the  subserous  connective  tissue  and  fat.  No  hard- 
and-fast  line  can,  of  course,  be  drawn  between  diseased 
conditions  of  the  epicardium  and  those  of  the  myocardium. 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  49 

If  one  is  affected,  the  other  of  necessity  must  be.  For  purposes 
of  classification  it  is  necessary,  however,  to  draw  a  distinction 
between  them. 

After  the  removal  of  the  sternum  and  costal  cartilages  the 
position  of  the  pericardial  sac  and  its  contents  as  regards  the 
other  structures  in  the  thoracic  cavity  should  be  noted,  also 
any  abnormal  distention  of  the  sac.  The  pericardial  sac  is, 
of  course,  one  of  the  serous  sacs  or  large  lymphatic  spaces  of 
the  body,  and  as  such  it  is  liable  to  conditions  which  tend  to 
affect  these  sacs.  Such  are  oedema  or  over-filling  of  these 
spaces  with  lymph,  inflammatory  conditions,  more  particularly 
in  acute  rheumatism. 

Hydropericardium,  or  dropsy  of  the  sac.  —  There  is 
always  a  small  quantity  of  clear,  straw-coloured  fluid  in  the 
sac  (about  £  oz.).  When  this  is  increased  to  any  extent  the 
term  dropsy  is  applied.  The  condition  is  usually  a  late 
manifestation  of  general  dropsy,  the  cause  being  commonly 
kidney  or  heart  disease.  (Edema  of  the  tissues  of  the 
pericardium  themselves  may  not  infrequently  be  observed, 
either  accompanied  by  dropsy  of  the  sac  or  without  it. 

Hsemopericardium,  or  blood  in  the  sac. — This  is  a  very 
rare  condition.  It  may  be  due  to  (i.)  a  penetrating  wound — 
bullet  wound  or  stab  ;  (ii.)  rupture  of  the  heart  from  (a) 
degenerative  changes  in  the  muscle  associated  with  obstruc- 
tion to  the  coronary  arteries  (common  position,  the  anterior 
aspect  of  the  left  ventricle  close  to  the  septum  and  not  far 
from  the  apex),  (b)  abscess  of  the  heart  wall  communicating 
with  one  of  the  cavities  (Fig.  16),  (c)  injury — &  crush  (common 
position,  base  of  heart) ;  (iii.)  rupture  of  an  aneurysm  of  the 
heart  itself,  of  one  of  the  coronary  arteries  or  of  the  commence- 
ment of  the  aorta ;  (iv.)  very  acute  inflammation  of  the 
pericardial  sac. 

Small  extravasations  of  blood  into  the  substance  of  the 
subpericardial  tissue  (ecchymoses  or  petechial  haemorrhages) 
are  fairly  common.  They  are  found  in  toxic  conditions  and 

4 


50  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

in  severe  anaemias.    They  are  chiefly  situated  at  the  base 
of  the  heart,  and  often  on  the  posterior  aspect. 

Pneumopericardium,  or  air  in  the  sac. — A  very  rare 
condition,  usually  associated  with  purulent  pericarditis  due 
to  rupture  of  the  oesophagus  or  stomach  into  the  sac.  The 
gas  may  be  due  to  the  presence  of  germs,  e.g.  B.  aerogenes 
capsulatus . 

INFLAMMATION   OF  THE   PERICARDIUM 
(PERICARDITIS) 

Types. 

1.  Acute  pericarditis. 

(a)  Fibrinous,  (b)  serous,  sero-fibrinous,  (c)  puru- 
lent, (d)  hsemorrhagic. 

2.  Chronic  pericarditis,  (a)  following  acute,  (b)  "  milk 

spot." 

3.  Adherent  pericardium. 

4.  Tuberculous  pericarditis. 

i.  Acute  Pericarditis. — This  is  due  invariably  to  the 
presence  of  some  germ.  Those  more  commonly  found  are 
micrococcus  rheumaticus,  staphylo cocci,  streptococci,  pneumo- 
cocci,  etc.  The  condition  occurs  in  the  course  of  acute 
rheumatism,  pyaemia,  pneumonia,  kidney  disease,  the 
organisms  reaching  the  per;cardial  sac  by  the  blood  or  by 
continuity  of  tissue  from  lung,  pleura,  mediastinum,  or 
heart  wall. 

The  essential  point  in  pericarditis  is  the  presence  of  an 
exudate  on  the  surface  of  the  pericardium  which  coagulates, 
thus  roughening  it  and  causing  it  to  lose  its  gloss.  The 
amount  of  this  exudate  may  be  very  small,  forming  a  mere 
roughness  on  the  surface,  or  it  may  occur  as  an  irregular, 
thick,  opaque,  white  layer  producing  a  shaggy  appearance 
(cor  villoswn)  (Fig.  15).  If  the  pericardial  surface  is  visible 
the  vessels  are  seen  to  be  injected.  The  exudate  may  be 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  51 

red  in  colour  from  haemorrhage.  The  amount  of  fluid  in 
the  sac  in  this  condition  is  variable.  Sometimes  it  is  small, 
forming  the  so-called  "  dry/'  plastic,  or  fibrinous  variety, 
found  more  especially  in  kidney  disease  and  in  pneumonia. 
More  commonly  there  is  some  free  fluid  with  flakes  of  lymph 
floating  in  it.  In  such  a  case  the  term  "  serous  "  or  "  sero- 
fibrinous "  may  be  applied.  In  some  cases  the  fluid  is 
purulent,  more  especially  in  pyaemia  or  septicaemia.  Occa- 
sionally, in  intense  inflammations,  blood  in  considerable 
amount  is  mixed  with  the  exudate  (hcemorrhagic  pericarditis). 
In  the  early  stages  the  fibrinous  exudate  can  easily  be  re- 
moved. Later  on,  when  organisation  has  commenced,  it 
will  be  found  bound  down  by  fine  threads  which  represent 
penetrating  young  blood-vessels. 

Microscopic  Appearances. — The  vessels  of  the  subpericardial 
tissue  are  dilated.  There  is  a  meshwork  of  fibrin  on  the 
surface  of  the  pericardium,  and  some  in  the  spaces  of  the 
tissue  itself.  Numerous  leucocytes  (chiefly  polymorphonuclear) 
are  found  infiltrating  the  pericardial  tissue  and  caught  in  the 
meshes  of  the  fibrin  on  the  surface.  In  the  early  stages  the 
endothelial  cells  are  swollen  and  vacuolated ;  later  they 
become  detached  and  occur  in  the  fibrin. 

Later  on,  evidence  of  organisation  of  the  exudate  is  found. 
The  endothelial  cells  of  the  vessels  of  the  subepicardial  tissue 
are  swollen  and  show  evidence  of  proliferation.  Small  buds 
can  be  seen  protruding  from  these  vessels  and  making  their 
way  into  the  fibrinous  exudate.  At  the  same  time  there  is 
swelling  and  proliferation  of  the  connective-tissue  cells  generally. 
The  newly  formed  cells  (fibroblasts),  which  are  at  first  small 
and  rounded,  with  a  fair  amount  of  pale-staining  protoplasm 
and  a  rounded,  relatively  small  nucleus,  accompany  the  newly 
formed  vessels  into  the  exudate.  Where  organisation  is 
advanced,  the  fibroblasts  farthest  from  the  pericardium  will 
still  be  rounded,  the  deeper  ones  will  be  spindle-shaped  and 
arranged  parallel  with  the  vessels  ;  still  nearer  the  pericardial 
surface  they  tend  to  lie  parallel  with  that  surface  and  perpen- 
dicular to  the  direction  of  the  new  blood-vessels.  From  the 


52  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

protoplasm  of  these  older  fibroblasts  the  collagenous  fibres  of 
the  new  tissue  are  developed. 

In  suitably   stained    specimens  micro-organisms  may   be 
found. 

Results :  (i)  the  exudate  may  be  absorbed,  and  matters 
return  to  the  normal. 

(2)  Organisation  with  union  between  heart  and  pericardial 
sac  may  take  place  (Adherent  Pericardium).     This  union 
may  be  partial  or  complete.     If  complete,  more  especially  if 
the  surrounding  tissues  of  the  mediastinum  participate  in  the 
inflammatory  process,  great  interference  takes  place  with  the 
action  of  the  heart,  with  the  result  that  it  tends  to  dilate. 

(3)  If  the  exudate  be  not  absorbed  it  may  be  the  seat 
of  deposit  of  lime  salts,  the  result  being  the  formation  of 
calcareous  plates.    This  is  a  rare  occurrence. 

2.  Chronic  Pericarditis. — This  may  follow  acute,  or  it 
may  develop  slowly,  the  result  of  friction,      (a)  Following 
acute,  the  condition  is  usually  associated  with  adhesion  be- 
tween visceral  and  parietal  pericardium,    (b)  A  more  common 
variety  of  it  consists  in  the  fibrous  thickenings  of  the  peri- 
cardium, of  ten  called  "milk  spots"  or  "soldier's  spots."  These 
are  white,  opaque,  well-defined  areas,  often  with  a  tendinous 
appearance.    They  are  most  frequently  found  on  the  anterior 
surface  of  the  right  ventricle.   Another  common  site  is  the 
anterior  surface  of  the  left  ventricle  close  to  the  apex.    Similar 
areas  are  often  found  thickly  covering  the  surface  of  the 
auricles.    They  are  also  not  infrequently  found  along  the 
course  of  the  coronary  arteries.    They  are  more  particularly 
found  in  hypertrophied  and  dilated  hearts,  and  are  due  to 
constant  friction. 

Microscopically  all  that  is   to  be  seen  is  a  thickening  of 
the  fibrous  tissue  under  the  endothelium. 

3.  Adherent  Pericardium. — This   condition  not  infre- 
quently follows  acute  fibrinous  pericarditis.      The  layers  of 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  53 

fibrin  on  visceral  and  parietal  pericardium  become  organised. 
Young  connective  tissue  forms  between  these  layers,  and  the 
heart  is  permanently  attached  to  the  pericardial  sac.  This 
may  occur  over  a  limited  area,  frequently  at  the  apex  of  the 
left  ventricle.  Very  often,  however,  it  occurs  all  over.  The 
inflammatory  change  may  also  spread  to  surrounding  struc- 
tures, such  as  pleura,  mediastinum.  The  mediastinal  glands 
are  enlarged  and  firm.  In  this  condition  the  heart  is  usually 
enlarged,  the  cavities  being  dilated  and  their  walls  thickened. 
There  is  backward  pressure  from  relative  incompetence  of 
the  valves,  and  chronic  venous  congestion  of  the  organs, 
such  as  lung,  liver,  and  spleen.  The  condition  not  in- 
frequently causes  death  from  constant  excessive  strain  on 
the  heart. 

4.  Tuberculous  Pericarditis. — This  may  occur  as  a  sub- 
acute  condition  associated  with  the  presence  of  small  grey 
and  yellow  nodules  of  tubercle.  It  is  often  combined  with 
general  miliary  tuberculosis.  Sometimes  the  tubercle  nodules 
are  found  along  the  course  of  the  coronary  vessels  without 
any  other  evidence  of  inflammation  being  present,  and  some- 
times there  is  excessive  distention  of  the  pericardial  sac  by 
fluid.  Tuberculous  pericarditis  is,  however,  a  rare  condition 
in  the  human  subject.  It  is  relatively  much  more  frequent 
in  the  bovine  species. 


DISEASES  OF  THE  MYOCARDIUM 

DEGENERATIVE  CHANGES 

Atrophy. — In  old  age  and  in  wasting  diseases,  such  as 
tuberculosis  and  cancer,  the  heart  tends  to  get  smaller, 
sometimes  being  reduced  to  one-third  of  its  usual  size.  As 
the  process  goes  on,  the  epicardium,  which  does  not  participate 
in  the  shrinkage,  becomes  wrinkled,  the  vessels  more  tortuous, 


54  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

and  the  fat  under  the  epicardium  reduced  in  amount.  At 
the  same  time  the  muscle  substance  becomes  a  darker  brown 
colour.  This  condition  is  known  as  brown  atrophy.  The 
brown  colour  is  due  to  the  increase  of  the  pigment  found 
normally  in  the  muscle  cells,  and  is  probably  a  coloured  fat 
or  lipochrome. 

Microscopically  the  individual  fibres  of  the  myocardium 
are  sometimes  smaller  than  normal,  but  the  main  change  is 
an  increase  of  the  golden  yellow  granules  of  pigment  which 
are  found  in  small  amount  normally  at  the  two  poles  of  the 
nuclei. 

Cloudy  Swelling. — This  condition  is  found  accompanying 
infective  diseases,  more  especially  those  associated  with  high 
temperature.  The  muscle  substance  is  pale,  soft,  and  friable. 
The  friability  can  be  tested  by  pushing  a  ringer  into  the 
muscle. 

Microscopically  there  is  often  very  little  alteration  to  be 
seen.  The  individual  fibres  are  somewhat  swollen  and 
granular,  and  there  may  be  some  loss  of  longitudinal  and 
occasionally  of  transverse  striation. 

Fatty  Changes. — Types. 

1.  Due  to  increase  in  the  subpericardial  fat. 

(a)  Fatty  loading. 

(b)  Fatty  infiltration. 

2.  Due  to  degenerative  changes  in  the  muscle  fibres 

(fatty  degeneration). 

(a)  Diffuse  form. 

(b)  Patchy  form. 

i.  Fatty  Loading  and  Fatty  Infiltration. — This  condition 
comes,  strictly  speaking,  under  diseases  of  the  pericardium, 
but  for  the  sake  of  contrast  with  fatty  degeneration  it  may 
be  taken  here. 

There  is  in  all  healthy  hearts  a  certain  amount  of  fat  in 
the  subpericardial  tissue,  more  especially  in  that  covering 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  55 

the  right  ventricle.  It  occurs  particularly  along  the  lines  of 
the  vessels  and  at  the  base  between  the  auricles  and  ventricles. 
In  very  fat  people  this  adipose  tissue  is  increased  in  amount, 
so  that  not  infrequently  the  whole  of  the  anterior  surface  of 
the  right  ventricle  may  be  covered  by  it.  This  is  what  is 
known  as  fatty  loading  of  the  heart.  The  increase  of  fat  may 
also  occur  in  anaemia  and  in  association  with  atrophy  of  the 
heart  muscle. 

As  the  fat  increases  in  amount  it  tends  to  make  its  way 
along  the  lines  of  the  vessels  which  penetrate  into  the  muscle 
substance,  leading  to  indistinctness  in  the  line  which  separates 
fat  from  muscle.  When  this  has  occurred,  the  term  fatty 
infiltration  is  applicable  (Fig.  18).  The  fat  in  this  way  tends 
to  separate  the  bundles  of  muscle  substance  from  one  another, 
and  to  cause  an  atrophy  of  these  by  pressure.  This  fatty 
infiltration  of  the  heart  often  accompanies  fatty  loading,  but 
it  may  occur  where  there  is  relatively  little  increase  in  the 
amount  of  subpericardial  fat. 

Microscopically,  the  rounded  fat  globules  can  be  seen 
passing  down  from  the  subpericardial  fat  along  the  lines  of 
the  vessels  into  the  muscle  substance.  The  muscle  fibres 
themselves  are  compressed  and  atrophied. 

2.  Fatty  Degeneration. — This  is  a  totally  different  condition 
from  the  preceding.  It  is  a  degenerative  change  in  the 
muscle  fibres  themselves.  It  is  found  more  especially  in  toxic 
conditions,  such  as  alcoholic  or  phosphorus  poisoning, 
bacterial  diseases,  and  in  severe  anaemias.  Two  forms  of 
it  are  distinguished  :  (i)  a  diffuse  form,  where  the  whole 
muscle  substance  is  uniformly  pale,  soft,  and  friable ;  (2)  a 
patchy  form,  which  is  usually  best  seen  towards  the  inner 
portion  of  the  wall  of  the  left  ventricle,  more  especially  in 
the  papillary  muscles.  In  this  position  the  muscle  has  a 
mottled  appearance,  with  small  transverse  parallel  patches — 
the  so-called  "  thrush  breast  "  mottling  or  "  tabby  cat  " 
striation. 


56  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

Microscopically  groups  of  muscle  fibres  are  found  contain- 
ing numerous  small  droplets  of  fat  in  their  protoplasm. 


ALTERATIONS  OF  THE  CIRCULATION 

Chronic  Venous  Congestion. — This  occurs  in  conditions 
where  there  is  backward  pressure  on  the  right  auricle  and 
therefore  on  the  blood  in  the  coronary  sinus.  It  is  accom- 
panied by  chronic  venous  congestion  in  other  organs.  The 
muscle  substance  is  firmer  and  thicker  than  usual  and  is  dark 
in  colour. 

Microscopically  there  is  distention  of  the  veins  and 
capillaries  with  blood. 

Effects  of  Obstruction  of  the  Coronary  Arteries  on  the 
Myocardium. — The  branches  of  the  coronary  arteries  within 
the  heart  belong  to  the  group  of  what  were  originally  called 
"  end  "  arteries.  They  are  not  as  a  matter  of  fact  entirely 
devoid  of  collateral  communications,  as  the  name  would 
indicate,  but  such  communications  as  they  have  are  small,  so 
that  when  a  branch  is  blocked  the  circulation  cannot  be  fully 
restored,  and  infarction  occurs.  The  effect  of  the  obstruction 
of  these  branches  upon  the  heart  depends  to  a  large  extent 
upon  whether  it  is  sudden  and  complete,  or  whether  it  occurs 
slowly y  and  is  therefore,  for  some  time  at  any  rate,  partial. 

i.  The  effect  of  sudden  obstruction  of  a  large  branch  of  one 
of  the  coronary  arteries  is,  as  a  rule,  to  produce  instant  death. 
When  the  branch  is  a  small  one  and  the  patient  survives, 
infarction  occurs.  The  cause  of  the  obstruction  is  either 
thrombosis  upon  an  atheromatous  patch  in  the  artery  or 
impaction  of  an  embolus.  More  usually  it  is  the  former. 
In  all  cases  of  unexplained  sudden  death  careful  search  should 
be  made  for  such  thrombi  by  slitting  up  the  branches  of  the 
coronary  vessels. 

The  infarcted  area  is  commonly  in  the  anterior  wall  of  the 
left  ventricle,  in  the  part  of  the  myocardium,  that  is  to  say, 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  57 

supplied  by  the  left  coronary  artery.  The  area  is  roughly 
triangular  in  shape,  with  the  broad  base  towards  the  interior 
of  the  ventricle.  It  may  be  red  or  pale.  In  the  early  stages 
it  is  usually  red,  becoming  pale  later  on,  as  necrosis  supervenes. 
Ultimately  connective  tissue  develops,  and  all  that  is  left 
is  a  fibrous  scar. 

Owing  to  the  weakening  of  the  muscle  at  the  point  of 
infarction,  aneurysmal  dilatation  of  the  wall  may  occur,  or 
even  sudden,  complete  rupture. 

Microscopic  Appearances. — In  the  early  stages  the  muscle 
is  found  infiltrated  with  red  blood  corpuscles.  The  muscle 
fibres  are  swollen,  have  lost  their  transverse  striation,  and 
stain  deeply.  The  nuclei  lose  their  staining  reaction.  Later, 
the  area  becomes  infiltrated  with  leucocytes  and  young  con- 
nective-tissue cells.  The  degenerated  fibres  are  absorbed 
and  connective  tissue  takes  their  place. 

2 .  Slow  Progressive  Narrowing  of  the  Coronary  Arteries. — This 
is  due  as  a  rule  to  thickening  of  the  intimafrom  atheromatous 
change.  It  leads  to  degenerative  changes  of  a  fatty  nature 
in  the  muscle  fibres  of  the  area  supplied,  and  a  gradual  replace- 
ment of  these  by  well-developed  fibrous  tissue.  As  it  is  the 
anterior  or  descending  branch  of  the  left  coronary  artery  which 
is  usually  the  seat  of  the  most  marked  change,  the  fibrosis 
occurs  in  the  wall  of  the  left  ventricle  near  its  apex,  in  the 
papillary  muscles  (Fig.  17),  and  in  the  interventricular  septum. 
Owing  to  the  weakening  of  the  heart  wall,  rupture  or 
aneurysmal  dilatation  may  occur.  The  change  produced 
is  precisely  the  same  as  that  described  under  chronic  interstitial 
myocarditis.  Indeed,  slow  progressive  narrowing  of  the 
branches  of  the  coronary  artery  is  the  commonest  cause  of 
that  condition. 

Aneurysm  of  the  Heart. — This  is  most  frequently  met 
with  towards  the  apex  of  the  left  ventricle.  The  causation 
in  such  cases  is  usually  progressive  narrowing  of  the  descending 
branch  of  the  left  coronary  artery.  The  connective  tissue 


58    DISEASES  OF  THE  HEART  AND  PERICARDIUM 

which  takes  the  place  of  the  degenerating  muscle  is  unable 
to  withstand  the  pressure  within  the  ventricle.  The  condition 
may  also  develop  acutely  from  infarction  of  the  heart  muscle 
or  acute  myocarditis  (Fig.  16).  On  the  inner  aspect  of  such 
dilatations,  thrombosis  tends  to  occur.  An  aneurysm  of 
one  of  the  sinuses  of  Valsalva  may  also  penetrate  the  heart 
muscle. 

INFLAMMATION  OF  THE  MYOCARDIUM 

(MYOCARDITIS) 
Types. 

1.  Acute  myocarditis. 

(a)  Non-suppurative,  (b)  suppurative. 

2.  Chronic  interstitial  myocarditis. 

(a)  Following  acute,  (b)  associated  with  narrowing 
of  the  coronary  arteries,  (c)  due  to  chronic 
inflammatory  conditions  (tubercle,  syphilis). 

1.  Acute  Myocarditis. — This  maybe  due  to  (i)  spread  of 
inflammation  from  the  pericardium  or  endocardium,  or  to 
(2)  blood  infection,  as  in  acute  rheumatism,  ulcerative  endo- 
carditis, pyaemia,  etc.    The  muscle  substance  may  show  little 
alteration  from  the  normal.     It  is  somewhat  soft,  friable, 
pale,     and     mottled.     In     the     special     type — suppurative 
myocarditis — small  abscesses  are  seen  as  minute  white  points 
surrounded  by  zones  of  congestion  and  haemorrhage.     Very 
occasionally  large  abscesses  may  form  which  lead  to  rupture 
of  the  heart  (Fig.  16). 

Microscopically  the  muscle  substance  is  found  infiltrated  with 
leucocytes,  more  especially  in  the  neighbourhood  of  vessels. 
The  leucocytes  may  be  aggregated  into  large  masses,  with 
haemorrhage  around  and  plugs  of  cocci  in  the  centre  of  the 
abscesses.  The  muscle  fibres  themselves  show  cloudy  swelling, 
or,  in  the  neighbourhood  of  abscesses,  actual  necrotic  change. 

2.  Chronic  Interstitial  Myocarditis. — In  this  condition 
there  is  a  replacement  of  the  muscle  substance  by  fibrous  tissue. 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  59 

It  may  (i)  follow  acute  myocarditis,  (2)  be  associated  with 
narrowing  or  obstruction  of  the  coronary  artery  or  its  branches, 
(3)  occur  in  connection  with  chronic  inflammatory  diseases, 
such  as  tubercle  and  syphilis.  The  commonest  cause  is 
undoubtedly  narrowing  of  branches  of  the  coronary  artery.  A 
slight  degree  of  the  condition  is  often  seen  in  old  age  due  to 
the  same  cause. 

The  condition  is  usually  most  marked  in  the  wall  of  the 
left  ventricle  near  the  apex.  It  should  also  be  sought  in 
the  papillary  muscles.  The  muscle  substance  in  these  areas 
is  partially  replaced  by  white  or  grey  fibrous  strands 
(Fig.  17).  The  endocardium  is  often  thickened  over  a 
corresponding  area  and  thrombosis  is  frequently  associated. 
The  condition  may  give  rise  to  aneurysmal  dilatation  of  the 
heart  wall. 

Microscopically  the  groups  of  muscle  fibres  are  found 
separated  from  one  another  by  bands  of  well-developed  fibrous 
tissue.  The  isolated  muscle  fibres  are  often  unusually  large, 
with  large,  dark-staining  nuclei. 

Syphilis  of  the  myocardium  is  occasionally  met  with 
either  as  gumma  formation  or  as  a  diffuse  interstitial  myo- 
carditis associated  with  arterial  disease. 

Tuberculosis  of  the  myocardium  is  also  a  very  rare 
condition.  It  may  be  met  with  as  small  miliary  tubercles 
or  as  large  caseous  masses. 

HYPERTROPHY  OF  THE  HEART 

A  general  hypertrophy  of  the  heart  occurs  in  those,  such 
as  athletes,  who  constantly  over-exert  themselves.  It  also 
occurs  in  pregnancy.  Hypertrophy  of  one  or  more  chambers 
of  the  heart  is  usually  associated  with  chronic  valvular 
lesions.  Conditions,  other  than  cardiac  lesions,  associated 
with  hypertrophy  of  certain  cavities  are  emphysema  and 


60  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

chronic  interstitial  disease  of  the  lungs  with  hypertrophy  of 
the  right  ventricle,  chronic  kidney  disease,  and  arteriosclerosis 
with  hypertrophy  of  the  left  ventricle  (Fig.  24). 

DILATATION  OF  THE  HEART 

General  dilatation  of  the  heart  is  found  in  association 
with  degenerative  changes,  such  as  cloudy  swelling  and  fatty 
degeneration.  The  dilatation  is  usually  most  marked  on 
the  right  side.  In  adherent  pericardium  of  any  marked 
degree  the  heart  as  a  whole  tends  to  dilate. 

Dilatation  of  the  right  side  is  found  as  a  rule  in  cases  of 
death  from  heart  failure.  It  also  occurs  in  chronic  valvular 
disease  involving  the  mitral  or  aortic  valve.  Dilatation  of 
the  left  ventricle  associated  with  hypertrophy  occurs  in  a 
marked  degree  in  cases  of  aortic  incompetence. 

Tumours  of  the  heart  are  excessively  rare.  Primary 
tumours  such  as  fibromata  or  myomata  are  described. 
Secondary  tumours  —  sarcomata  and  carcinomata  —  occa- 
sionally occur,  but  may  involve  the  heart  very  extensively 
before  they  result  in  death. 


DISEASES   OF   THE   ENDOCARDIUM 

DEGENERATIVE   CHANGES 

Bed  staining  of  the  endocardium  is  found  as  a  result  of 
putrefactive  processes,  also  in  septic  conditions.  It  is  due  to 
the  setting  free  of  haemoglobin  from  the  red  blood  cells. 

Small  haemorrhages  may  occur  under  the  endocardium  in 
infective  conditions  and  anaemia. 

Areas  of  fatty  degeneration  occur  as  white  specks  or 
patches,  more  especially  in  infective  conditions,  in  anaemias, 
and  in  cases  of  phosphorus  and  chloroform  poisoning.  These 
areas  occur  chiefly  on  the  valves.  Under  the  microscope  the 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  61 

protoplasm  of  the  endothelial  and  of  the  subjacent  connective- 
tissue  cells  is  found  filled  with  fat  globules. 

Calcareous  and  uratic  deposits  are  found  more  especially 
in  the  valves,  and  chiefly  in  association  with  chronic  inflam- 
mation. They  appear  as  opaque  white  or  yellow  areas  of 
thickening,  sometimes  with  a  roughened  surface,  on  which 
thrombi  may  be  deposited. 

Atheromatous  change,  both  the  early  stage  with  thicken- 
ing of  the  endocardium  and  fatty  degeneration  and  the  later 
stage  of  calcification,  may  be  found,  more  especially  as  an 
extension  from  the  aorta.  There  is  no  hard-and-fast  line 
between  this  condition  and  the  fatty  change  already  men- 
tioned. 

CLOTS  IN  THE  HEART 

Thrombi  are  clots  formed  within  the  heart  or  the  vessels 
during  life.  In  the  heart  they  form  chiefly  where  the  blood 
current  is  slow  or  where  there  are  eddies.  These  conditions 
are  present  more  especially  in  the  auricular  appendices. 
The  commonest  site  for  thrombi  is  the  right  auricular  appendix 
(Fig.  19).  Thrombi  also  occur  in  the  ventricles  towards  the 
apex,  when  they  are  usually  associated  with  degenerative 
changes  in  the  myocardium.  They  also  occur  behind  the 
curtains  of  the  auriculo- ventricular  valves.  They  are 
frequent  on  the  surfaces  of  the  valves,  being  known  in  this 
situation  as  vegetations. 

Thrombi  are  usually  of  the  mixed  red  and  white  type. 
The  colourless  portions  are  opaque  white,  and  more  or  less 
stringy.  Thrombi  are  usually  adherent  to  the  heart  wall. 

When  thrombi  are  present  in  the  chambers  of  the  heart 
infarcts  should  be  looked  for  in  the  various  organs.  If  the 
thrombus  is  on  the  right  side  the  infarcts  will  be  found  in 
the  lung  (except  in  the  rare  case  of  a  patent  foramen  ovale), 
if  on  the  left  side  the  infarcts  may  be  in  brain,  spleen,  kidney 
or  intestine  (see  Diagram,  p.  62). 


Plan  of  the  Circulation  to  show  the  Origin  and  Destination  of  the  more 

common  Emboli. 

i,  i,  i  are  thrombi  in  iliac  vein  (I.V.),  or  its  branches,  e.g.  superficial  veins  of  leg 
uterine  veins,  Superior  Vena  Cava  (S.V.C.)>  or  its  branches,  e.g.  cerebral  sinuses, 
right  auricular  appendix  (R.A.A.)  and  right  ventricle  (R.V.),  which  may  give 
rise,  by  washing  away  of  portions,  to  infarcts  (li)  in  the  lung  (Lu).  2,  2,  2  are  thrombi 
in  left  auricular  appendix  (L.A.A.),  on  mitral  valve  (M.V.)>  in  left  ventricle  (L.V.),  on 
aortic  valve  (A.V.)  and  on  wall  of  aorta  (A),  which  may  give  rise,  by  washing  away 
of  particles,  to  infarcts  2i,  2i,  2i  in  brain  (B),  intestine  (i),  spleen  (S),  kidney  (K). 
3  is  a  thrombus  in  rootlet  of  portal  vein  (PV)  which  might  give  rise  to  infarction  or, 
if  septic,  to  abscess-formation  in  the  liver  (L). 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  63 

Post-mortem  clots,  on  the  other  hand,  are  red  or  yellow, 
translucent  or  transparent,  jelly-like  masses  which  are  not 
adherent.  Clots  often  cling  to  the  columnae  carneae,  but  they 
are  not  really  adherent  to  the  heart  wall. 

"  Agonal "  clots  occupy  a  position  between  the  true 
thrombi  and  the  post-mortem  clots.  They  are  more  opaque 
than  the  clots,  they  may  be  stringy,  but  are  not  adherent. 
They  are  found  more  particularly  on  the  right  side  of  the 
heart,  extending  up  into  the  pulmonary  artery.  They  may 
completely  fill  the  right  auricle  and  ventricle.  They  are 
found  especially  in  pneumonia  and  other  infective  conditions. 

Rounded  thrombi  lying  free  in  the  auricles,  so-called 
"  ball  "  thrombi,  are  sometimes  found  in  cases  of  stenosis  of 
the  mitral  valve.  They,  as  well  as  other  thrombi  in  the 
auricles,  often  show  softening,  sometimes  liquefaction  of  their 
interior  (red  or  simple  softening). 

(For  microscopic  appearances  of  thrombi,  see  p.  88.) 


Thrombi. 

Agonal  Clots. 

Post-mortem 
Clots. 

Position. 

Auricular  appendices, 
valves  (vegetations). 
Apices  of  ventricles. 

Mainly  right  auricle, 
ventricle  and  pul- 
monary artery. 

Anywhere,  but 
chiefly       on 
right  side. 

Appearances. 

Opaque,  white,  buff- 
coloured  or  red. 

Semi-opaque.    Often 
fill  cavity. 

Transparent. 

Consistence. 

Stringy,  friable,  some- 
times softened  in 

Soft  and  gelatinous. 

centre. 

Relations 
to      heart 
walls. 

Adherent.  When 
broken  off,  leaving 
portions  behind. 

Non-adherent.    May  cling  to  columnse 
carneae,  hordae  tendinaceae,  etc. 

Associated 

Chronic  valvular    dis- 

Infective   conditions    such  as    acute 

diseased 
conditions 

ease  of  heart. 
Chronic   interstitial 

lobar   pneumonia,   pyaemia,   septi- 
caemia. 

myocarditis.    Aneu- 
rysm  of  heart  wall. 

64  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

INFLAMMATION  OF  THE  ENDOCARDIUM 
(ENDOCARDITIS) 

The  endocardium  possesses  no  direct  blood-supply,  nor 
do  the  semilunar  or  auriculo-ventricular  valves.  This  fact 
in  all  probability  accounts  for  the  rarity  of  inflammatory 
phenomena  in  the  ordinary  sense  of  the  term  in  connection 
with  these  structures.  On  the  other  hand,  the  intimate 
connection  between  endocardium  and  valves  and  the  circulating 
blood  renders  these  structures  peculiarly  susceptible  to  the 
action  of  germs  or  poisons  which  may  be  present  in  the  blood- 
stream. Once  the  endocardium  is  damaged,  thrombosis  tends 
to  occur  upon  the  injured  surface,  with  the  formation  of  what 
are  called  vegetations.  Another  fact  in  the  production  of 
the  more  chronic  types  of  endocarditis  is  strain.  Thus  the 
valves  of  a  dilated  and  powerfully  acting  heart  tend  to  become 
thickened. 

Types. 

1.  Acute  endocarditis. 

(a)  Simple  or  vegetative. 

(b)  Ulcerative  or  malignant. 

2.  Chronic  endocarditis. 

(a)  Following  acute. 

(b)  Associated  with  atheroma. 

(c)  Associated  with  strain. 

i.  Acute  Endocarditis. — This  condition  is  probably  in- 
variably due  to  the  presence  of  germs  upon  the  endocardium. 
Two  sub- varieties  are  distinguished :  (a)  simple  or  vegetative, 
and  (b)  ulcerative  or  malignant.  There  is  no  hard-and-fast 
line  between  these  two.  They  are  both  due  to  the  presence 
of  germs,  and  may  be  due  to  the  same  germs.  The  simple 
type,  however,  has  a  very  constant  relationship  to  acute 
rheumatism,  and  is  thus  caused  probably  by  the  micrococcus 
rheumaticus.  The  malignant  type  may  be  caused  by  a 
variety  of  germs,  such  as  pneumococcus ,  streptococci,  staphy- 
lococci,  gonococcus. 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  65 

In  both  varieties  the  essential  change  is  the  presence  on 
the  damaged  valve  of  vegetations  or  thrombi,  and,  as  stated 
above,  no  hard-and-fast  line  can  be  drawn  between  the  two 
conditions.  In  deciding  in  any  case  as  to  which  condition 
is  present  the  following  points  should  be  attended  to.  (i) 
Character  of  vegetations.  These  in  the  ulcerative  type  tend 
to  be  larger  and  more  friable.  (2)  Extent.  In  simple 
endocarditis  the  vegetations  are  limited  to  a  line  close  to  the 
free  margin  of  the  valve ;  in  ulcerative  endocarditis  they 
extend  not  merely  all  over  the  valve  but  on  to  the  surface 
of  auricle  in  the  case  of  mitral  disease,  on  to  aorta  or  heart 
wall  in  the  case  of  aortic  disease ;  also  in  the  case  of 
the  mitral  valve  they  extend  on  to  the  chordae  tendinese. 
(3)  Effect  on  valves.  In  the  case  of  simple  endocarditis 
beyond  swelling  of  the  valve  no  special  change  is  observed. 
In  the  ulcerative  type  destruction  of  the  valve,  aneurysm  or 
rupture  of  the  valve  or  of  the  chordae  tendinese  is  often 
met  with.  As  regards  the  site,  both  varieties  are  found 
much  more  commonly  on  the  left  side  of  the  heart.  When 
endocarditis  occurs  during  foetal  life  it  is  found  more  fre- 
quently on  the  right  side. 

(a)  Simple  Acute  Endocarditis. — This  is  usually  met  in 
connection  with  the  mitral  and  aortic  valves,  more  rarely 
on  tricuspid  or  pulmonary  valves.  It  is  most  commonly 
associated  with  acute  rheumatism,  but  may  be  found  in  cases 
of  tonsillitis,  chorea,  scarlet  fever,  and  septicaemia .  The 
valves  themselves  are  somewhat  swollen,  and  on  the 
segments  is  a  fringe  consisting  of  larger  or  smaller  numbers 
of  warty  projections  (vegetations)  (Figs.  20  and  21).  These 
vegetations  are  found  not  at  the  free  margin  but  on  a  line 
a  short  distance  from  that  margin.  In  the  case  of  the 
mitral  valve  they  are  to  be  found  on  the  upper  or  auricular 
surface,  in  the  case  of  the  aortic  valve  on  the  lower  or 
ventricular.  The  line  on  which  they  occur  is  that  of 

5 


66  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

maximum  pressure  of  the  valves  during  closure.  The 
vegetations  may  be  soft,  friable,  and  easily  removed,  or  firm 
and  adherent.  Infarcts  are  frequently  found  in  such  organs 
as  spleen  and  kidney. 

Microscopic  Appearances. — The  various  cellular  and  fibrous 
elements  in  the  valve  are  separated  from  one  another  owing 
to  oedema.  There  may  be  fibrin  present  in  the  connective- 
tissue  spaces,  and  usually  polymorphonuclear  leucocytes  and 
young  connective-tissue  cells  and  other  wandering  cells  are 
found,  in  addition  to  the  fixed  tissue  elements.  On  the  surface 
of  the  valve  there  is  a  mass  of  granular  material  staining 
with  acid  dyes,  and  consisting  of  blood  platelets  and  fibrin. 
In  addition  there  may  be  fibrin  threads.  There  are  usually 
numerous  white  blood  corpuscles  which  are  found  in  groups. 
Red  cells  may  be  present  at  the  free  margin,  and  masses  of 
germs  can  be  demonstrated  by  suitable  methods  in  some  cases. 
In  the  later  stages  evidence  of  organisation  may  be  found  at 
the  junction  of  valve  and  thrombus.  Spindle-shaped  and 
rounded  cells  may  be  seen  making  their  way  in  from  the  valve 
to  the  vegetation.  These  are  fibroblasts  resulting  from  the 
division  of  the  connective-tissue  cells  of  the  valve. 

(b)  Ulcerative  Endocarditis. — In  this  type  the  valve  may 
present  the  same  appearance  of  slight  swelling.  It  is  often 
thickened  from  previous  endocarditis.  The  vegetations  tend 
to  be  larger  and  more  friable.  They  are  not  limited  to  the 
margin  of  the  valve  but  extend  on  to  auricle  or  chordce  tendinece 
(Fig.  22),  ventricle,  or  aorta.  There  may  be  destruction  of 
the  valve  substance  with  ulceration,  aneurysmal  dilation  of  a 
segment,  or  complete  rupture  (Fig.  23).  Rupture  of  such 
structures  as  chordce  tendinece  also  occurs.  Owing  to  the 
greater  friability  there  is  an  increased  tendency  to  embolism 
and  infarction.  Also  the  infarcts  may  be  septic. 

Microscopically,  the  infiltration  of  the  valve  with  inflam- 
matory cells  is  more  marked.  The  other  appearances  are 
the  same,  except  that  masses  of  micro-organisms  tend  to  be 
larger  and  more  numerous.  Actual  destruction  of  the  valve 
substance  may  be  found. 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  67 


Simple  or  Vegetative.  Malignant  or  Ulcerative. 


Character    of 
vegetations. 

Extent. 


Appearance  of 
valves. 


Associated 
conditions. 


Causal  organ- 
ism. 


Small,  firm. 


Limited  to  line  close  to 
free  margin  of  valve. 


Very  little  alteration, 
slight  swelling. 


Chorea,  acute  rheu- 
matism, scarlet  fever, 
infarcts  in  spleen, 
etc. 

Micrococcus  rheumati- 
cus,  found  in  many 
cases. 


Large,  friable. 


Tendency  to  extend  to  wall  of 
auricle,  and  ventricle,  to 
chordae  tendineae,  aorta,  etc. 

Destruction  of  valve,  aneur- 
ysm- formation,  rupture  of 
valve  or  chordae  tendineae. 
Valve  often  already  thick- 
ened from  previous  acute 
endocarditis. 

Pyaemia,  greater  tendency  to 
formation  of  infarcts  and 
embolic  abscesses. 


Pneumococcus,     Gonococcus, 
Staphylococci,  Streptococci. 


Results  of  Acute  Endocarditis. 

(a)  The  conditions  may  return  to  the  normal,  the  inflam- 
matory exudate  and  vegetations  being  absorbed. 

(b)  The  proliferated  connective -tissue  cells    may  settle 
down  and  form  new  connective  tissue,  vessels  at  the  same 
time  penetrating  the  valve  from  the  nearest  vascular  area. 
The  new  connective  tissue  shrinks  and  the  valve  remains 
permanently  thickened  and  altered.     In  other  words,  what  is 
called  chronic  endocarditis  supervenes.    This  very  frequently 
happens  with  resulting  stenosis  or  incompetence  of  the  valve. 

(c)  A  second  attack  is  not  infrequent  when  a  valve  has  once 
been  the  seat  of  inflammatory  change.    As  already  stated, 
the  ulcerative  type  tends  specially  to  occur  in  the  case  of 
valves  already  damaged. 


68  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

(d)  Embolism  and  infarction  due  to  blocking  of  branches 
of  the  systemic  arteries  are  very  commonly  met  with,  more 
especially  in  the  case  of  the  ulcerative  type  of  the  disease. 

2.  Chronic  Endocarditis. — This  condition  may  (i)  follow 
an  acute  endocarditis  owing  to  organisation  and  subsequent 
laying  down  of  new  connective  tissue,  (2)  arise  slowly  owing 
to  the  action  of  chronically  acting  poisons,  such  as  lead, 
alcohol,  syphilis,  retained  products  of  metabolism  (gout),  or 
(3)  it  may  be  due  to  strain.  Chronic  thickening  of  the 
endocardium  lining  the  cavities  of  the  heart  occurs  sometimes 
when  the  cavities  are  the  seat  of  chronic  dilatation. 

The  valve  which  is  the  seat  of  this  change  is  thickened. 
The  thickening  may  be  chiefly  at  the  line  of  attachment, 
may  be  near  the  margin,  or  may  occur  throughout.  The 
valve  is  thus  opaque  and  white  or  yellow  in  colour.  The 
segments  are  usually  shrunken,  misshapen,  and  may  be  united 
together  so  that  the  orifice  is  narrowed  (Figs.  26  and  27). 
Such  thickened  valves  are  often  the  seat  of  calcareous 
deposits  which  appear  as  more  opaque,  yellow  masses  in  the 
substance  of  the  valve.  Sometimes  the  endocardium  over 
the  calcareous  deposit  necroses  from  want  of  nourishment, 
and  so  thrombus  formation  may  take  place  upon  the  cal- 
careous surface  laid  bare. 

Microscopically  such  valves  may  show  little  beyond  an 
amount  of  well-developed  fibrous  tissue  greater  than  usual. 
Hyaline  degeneration  may  take  place  in  this  connective  tissue, 
also  calcareous  deposit. 

Results  of  Chronic  Endocarditis. — The  chief  results  are  : 
(i)  Narrowing  of  the  valve  from  adhesion  between  its 
segments,  contraction  of  its  fibrous  elements,  or  from  both 
causes  (stenosis).  (2)  Failure  of  the  valve  to  perform  its 
function  of  closure  of  the  orifice,  due  to  shrinkage  and  contrac- 
tion of  its  segments  (incompetence).  In  consequence  of 
these  two  results  of  the  changes  in  the  valves  themselves  an 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  69 

extensive  series  of  alterations  may  take  place  in  the  various 
chambers  of  the  heart  and  in  the  circulation  generally.  The 
diseased  condition  of  the  valves,  with  the  accompanying 
changes  in  the  circulation,  is  generally  known  as  chronic 
valvular  disease  of  the  heart.  According  to  the  valve  affected 
and  the  type  of  the  lesion,  different  varieties  are  distinguished. 

EFFECT  ON  THE  HEART  AND  CIRCULATION  OF 
THE  DIFFERENT  TYPES  OF  CHRONIC  VAL- 
VULAR DISEASE 

i.  Mitral  Stenosis. — This  is  perhaps  the  best  defined 
type  of  chronic  valvular  disease.  It  is  found  chiefly  in 
women,  and  is  due  invariably  to  the  adhesion,  shrinking, 
and  contraction  of  the  two  segments  of  the  mitral  valve 
following  acute  endocarditis  of  the  valve,  very  often  of 
rheumatic  origin.  The  valve  is  thickened,  opaque,  the 
segments  are  united  together,  and  the  opening  may  be  a  slit 
and  nearly  flush  with  the  attachment  of  the  valve  (buttonhole 
mitral)  (Fig.  26),  or  more  or  less  circular  and  some  distance 
below  the  level  of  the  attachment  of  the  segments  (funnel- 
shaped  mitral).  The  amount  of  narrowing  varies  in  different 
cases.  Occasionally  the  contraction  is  so  marked  that  the 
valve  will  not  admit  the  tip  of  the  finger,  scarcely  a  crow 
quill. 

The  process  of  narrowing  occurs  slowly,  so  that  the  effect 
is  only  gradually  felt  by  the  heart.  This  being  the  case,  the 
left  auricle,  upon  which  the  strain  falls,  gradually  dilates  and 
its  wall  thickens  in  order  to  overcome  the  obstruction.  For 
a  time  the  hypertrophied  left  auricle  may  be  equal  to  the 
task  of  driving  the  blood  through  the  narrowed  orifice. 
Eventually,  however,  the  tendency  is  for  the  backward 
pressure  to  tell  upon  the  pulmonary  circulation,  so  that  the 
lungs  show  chronic  venous  congestion.  Not  infrequently 
the  pulmonary  artery  exhibits  in  this  condition  well-marked 


70  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

patches  of  fatty  change  (atheroma).  Through  the  lungs 
the  pressure  tells  back  upon  the  right  side  of  the  heart,  the 
cavities  of  which  become  dilated  and  their  walls  thickened 
(Fig.  25).  At  the  same  time  the  backward  pressure  tells  upon 
the  whole  venous  system,  with  the  result  that  chronic  venous 
congestion  develops  in  all  the  organs  and  viscera,  including 
the  heart,  as  well  as  in  the  tissues  and  limbs.  The  degree  of 
this  congestion  depends  upon  the  capacity  of  the  heart  to 
respond  to  the  demands  made  upon  it.  When  the  heart 
fails  to  respond,  or,  as  it  is  usually  expressed,  when  com- 
pensation fails,  the  congestion  becomes  extreme,  and  oedema 
or  dropsy  tends  to  appear,  more  especially  in  the  tissues  of 
the  lower  limbs. 

The  left  ventricle  in  mitral  stenosis  tends  to  receive  less 
blood  than  usual.  Its  work  is  not  necessarily  interfered 
with.  In  consequence,  it  either  does  not  enlarge  or  it  may 
even  become  smaller.  A  degree  of  incompetence  of  the 
valve  is  usually  present  in  mitral  stenosis,  especially  in 
advanced  cases  owing  to  stiffness  of  the  segments.  In  cases 
where  the  incompetence  is  marked  the  left  ventricle  will  tend 
to  dilate. 

2.  Mitral  Incompetence. — This  lesion  may  occur  alone, 
or  it  may  be  combined  with  a  degree  of  narrowing.  It  may 
be  associated  with  thickening  and  contraction  of  the  valves 
from  a  previous  acute  attack  of  endocarditis,  or,  on  the  other 
hand,  the  incompetence  of  the  valve  may  be  merely  relative, 
due  to  a  lax  or  stretched  condition  of  the  band  of  circular 
muscle  fibres  which  surround  the  base  of  the  valve  and 
assist  in  its  closure,  or  due  to  dilatation  of  the  ventricle 
carrying  outward  the  attached  papillary  muscles.  In  appear- 
ance the  valves  are  usually  thickened,  shrunken,  and  con- 
tracted towards  their  attachment.  Not  infrequently  the 
chordae  tendineae  are  also  thickened  and  shortened.  The 
lesion  is  associated  with  dilatation  and  hypertrophy  of  the 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  71 

left  ventricle,  then  of  the  left  auricle.  The  lungs  become 
congested,  and  through  the  lungs  the  pressure  tells  back 
upon  the  right  side  of  the  heart.  Thus  the  heart  in  this  con- 
dition tends  to  undergo  more  or  less  uniform  enlargement. 

3.  Aortic  Incompetence. — This  condition  is  due  to 
thickening  and  shrinking  of  the  segments  of  the  aortic  valve. 
It  is  often  associated  with  a  degree  of  stenosis.  The  cause 
may  be  :  (a)  a  previous  acute  endocarditis  of  the  aortic 
valve  which  is  not  infrequently  associated  with  endocarditis 
of  the  mitral  valve  ;  (b)  the  spread  of  disease  (atheromatous 
or  syphilitic)  from  the  aorta ;  (c)  occasionally  it  may  be 
due  to  traumatic  rupture  of  a  segment  which,  however,  is 
usually  already  the  seat  of  chronic  changes  ;  (d)  very  rarely  it 
is  caused  by  congenital  malformation  or  fcetal  disease.  The 
condition  occurs  most  commonly  in  men  and  in  later  life. 

In  consequence  of  the  failure  of  the  segments  to  close 
the  orifice  during  diastole,  blood  flows  backwards  again  into 
the  left  ventricle  from  the  aorta.  The  cavity  has  thus  to 
accommodate  this  blood  in  addition  to  what  comes  normally 
through  the  mitral  orifice.  The  left  ventricle  therefore 
dilates.  At  the  same  time  the  wall  of  the  cavity  hyper- 
trophies in  order  to  drive  on  the  large  quantity  of  blood. 
This  dilatation  and  hypertrophy  of  the  left  ventricle  is  often 
very  great.  The  largest  hearts  on  record  are  from  cases  of 
aortic  incompetence.  The  term  cor  bovinum  has  been 
applied  to  them.  Subsequently,  owing  to  the  great  dilatation 
of  the  left  ventricle,  a  relative  incompetence  of  the  mitral 
valve  may  be  brought  about.  Thus  there  is  backward 
pressure  on  the  left  auricle,  then  on  the  lungs  and  the  right 
heart.  Owing  to  the  injection  of  the  blood  into  the  aorta 
by  the  powerfully  acting  left  ventricle,  aneurysmal  dilatation 
of  the  aorta  may  occur,  more  especially  as  the  vessel  is 
frequently  the  seat  of  disease.  Owing  to  the  rapid  empty- 
ing of  the  arteries,  those  going  to  the  head  are  badly  supplied 


72  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

with  blood.  Hence  the  marked  pallor  of  individuals  suffer- 
ing from  this  condition,  and  hence  the  tendency  to  fatal 
syncope. 

4.  Aortic   Stenosis.— This  is  usually   accompanied   by 
more  or  less  incompetence.    The  cause  may  be  a  previous 
attack  of  acute  endocarditis,  or  it  may  be  associated  with 
atheroma  of  the  aorta.    The  segments  of  the  valve  are 
thickened  and  often  the  seat  of  calcareous  change.    They 
are  usually  united  together,  sometimes  leaving  only  a  minute 
aperture  for  the  passage  of  the  blood  (Fig.  27).    The  effect 
upon  the  heart  is  to  cause  hypertrophy  of  the  left  ventricle, 
which  is  usually  at  the  same  time  dilated,  owing  to  the  exist- 
ence of  a  certain  amount  of  incompetence. 

5.  Tricuspid  incompetence  is  the  commonest  valvular 
lesion  on  the  right  side  of  the  heart,  and  is  most  commonly 
merely  relative,  due  to  a  dilated  condition  of  the  right 
ventricle.    It   is   more   rarely  due   to   endocarditis,  either 
during  extrauterine  or  foetal  life.     It  leads  to  dilatation  and 
some  hypertrophy  of  the  right  auricle,  and  is  associated  with 
marked  venous  engorgement,  and  often  with  pulsation  in  the 
veins  of  the  neck  and  in  the  liver. 

6.  Tricuspid  stenosis  is  a  rare  condition  by  itself.    It 
is  usually  associated  with  stenosis  of  the  mitral  valve.  It  is  due 
to  endocarditis  occurring  either  during  foetal  or  extrauterine 
life. 

7.  Lesions  of  the  pulmonary  valve  are  very  rare,  and 
are  usually  congenital,  being  due  either  to  malformation  or 
foetal  endocarditis. 

(EDEMA  OR  DROPSY  IN  CARDIAC  DISEASE 

When  the  heart  is  failing  from  degenerative  changes  in 
its  musculature  or  from  dilatation  associated  with  chronic 
valvular  disease,  oedema  tends  to  appear.  Cardiac  oedema 
is  usually  distributed  about  the  body  in  accordance  with  the 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  73 

effect  of  gravity,  appearing  first  and  being  most  marked  in 
the  more  dependent  parts,  such  as  the  tissue  round  the  ankles. 
Later  on  it  spreads  to  other  parts  and  to  the  serous  sacs — 
peritoneum,  pleura,  pericardium.  As  regards  the  causation 
ofjthis  type  of  cedema,  increased  pressure  within  the  capillaries 
from  venous  congestion  is  certainly  an  important  factor. 
Experimentally  produced  venous  obstruction  is,  however, 
not  necessarily  followed  by  dropsy.  Another  factor  must  be 
presupposed.  This  factor  is  the  damage  to  the  endothelium 
due  to  defective  nutrition  of  the  cells  from  mal-oxygenation 
of  the  blood  and  retention  of  waste  products.  At  the  same 
time  there  is  also  obstruction  to  the  lymphatic  return  owing 
to  the  fact  that  the  larger  lymph  channels  open  into  veins 
over-distended  with  blood. 

PRIMITIVE  MUSCULAR  TISSUE  OF  THE  HEART  AND 
ITS  RELATION  TO  "  HEART  BLOCK  " 

There  are  two  main  portions  of  primitive  muscular  tissue 
which  should  be  examined  : — 

(1)  The    sino-auricular   node^    the    site    of  origin   of  the 
normal   stimuli  for  the  heart's   contraction  which  is  situated 
between  the  opening  of  the  superior  vena  cava  and  the  right 
auricular  appendix.      It  is  composed  of  slender  muscle  fibres, 
nerve-cells  and  fibres.      It  has  been  found  to  show  subacute 
and  chronic  inflammatory  change  in  cases  of  arrhythmia. 

(2)  The  auricula-ventricular  bundle -,  which  starts  from  the 
auriculo-ventricular  node,  situated    on   the    right   side  of  the 
inter-auricular  septum  in  front  of  the  opening  of  the  coronary 
sinus,  and  above  the    attachment  of  the   septal   cusp  of  the 
tricuspid   valve.      The   auriculo-ventricular   node    consists    of 
tissue  similar  to  the  sino-auricular  node.      From  the  node  the 
bundle  runs  forward  almost  horizontally,  but  somewhat  down- 
wards, and  usually  to  the  left  in  the  pars  membranacea  septi. 
At  the  anterior  part  of  the  membrane,  a  little  in  front  of  the 
anterior  end   of  the   attachment   of  the  median  and  septate 
segments  of  the  tricuspid  valve,  the  bundle  divides  into  two 
parts.     The  left  division  passes  downwards  and  perforates  the 


74  DISEASES  OF  THE  HEART  AND  PERICARDIUM 

membrane,  entering  the  subendocardial  tissue  of  the  left 
ventricle  at  a  point  immediately  beneath  the  union  of  the 
anterior  and  right  posterior  cusps  of  the  aortic  valve.  It 
then  spreads  out  in  a  fan-shaped  fashion  under  the  endocardium 
of  the  left  side  of  the  septum,  going  to  the  papillary  muscles 
of  the  mitral  valve  and  the  ventricular  muscle.  The  right 
branch  runs  downwards  and  enters  the  moderator  band,  and 
subsequently  passes  to  the  papillary  muscles  and  wall  of  right 
ventricle. 

In  cases  of  "heart  block"  the  bundle  has  been  found 
implicated  or  destroyed  in  some  part  of  its  course.  The 
lesions  found  have  been  :  (i)  Acute  inflammation  from  spread 
ofulcerative  endocarditis  of  mitral  or  aortic  valve;  (2)  chronic 
interstitial  myocarditis  and  sometimes  calcification  associated 
with  arteriosclerosis  of  the  coronary  artery ;  (3)  fibrosis 
following  acute  rheumatic  inflammation  of  myocardium ; 
(4)  fatty  infiltration;  (5)  tumour  formation,  e.g.  sarcoma; 
(6)  gumma  of  heart  wall ;  (7)  aneurysm  of  one  of  the 
sinuses  of  Valsalva  involving  the  septum. 

GENERAL  METHOD  OF  SETTING  ABOUT  THE  EXAMINA- 
TION OF  A  HEART  WHICH  HAS  BEEN  EXCISED  AND 
OPENED  UP 

Note  in  the  first  instance  the  size  of  the  organ.  A  rough 
approximation  to  the  normal  size  of  a  heart  is  obtained  by 
comparing  it  with  the  closed  fist  of  the  individual.  Next 
note  the  shape.  The  normal  heart  is  conical.  This  shape 
is  retained  when  the  heart  is  enlarged,  if  that  enlargement  be 
due  to  uniform  increase  in  size  of  all  the  cavities.  If,  however, 
the  left  ventricle  be  hypertrophied  (as  in  kidney  and  arterial 
disease)  out  of  proportion  to  the  rest,  although  still  conical  the 
organ  is  elongated.  In  cases  where  the  right  side  of  the 
heart  is  enlarged  out  of  proportion  to  the  left,  as  in  mitral 
stenosis  and  in  chronic  pulmonary  disease,  the  organ,  instead 
of  being  conical,  is  ovoid  (Fig.  15). 

Next  examine  the  visceral  pericardium  for  milk  spots, 
petechial  haemorrhages,  fibrinous  exudate,  adhesions  to  the 
pericardial  sac.  Then  turn  to  the  right  side  and  examine  the 
right  auricle  as  to  its  size,  the  thickness  of  its  walls,  its 
contents  (looking  more  especially  for  thrombi  in  the  appendix). 


DISEASES  OF  THE  HEART  AND  PERICARDIUM  75 

Next  examine  the  right  ventricle  as  to  its  size,  the  thickness 
of  the  walls,  the  amount  of  fat  in  the  subpericardial  tissue, 
and  whether  this  fat  is  actually  invading  the  muscle  substance. 
Estimate  the  diameter  of  the  tricuspid  valve  and  examine  its 
segments  for  thickening  and  vegetations.  The  diameter  may 
be  measured  roughly  with  the  fingers.  The  opening  normally 
admits  three  digits.  Glance  at  the  pulmonary  valve  for  the 
presence  of  thickening  and  vegetations. 

Now  turn  the  heart  round  and  examine  the  left  auricle  as 
to  size,  thickness  6f  walls,  thickening  of  the  endocardium,  the 
presence  of  vegetations  or  thrombi  (more  especially  in  the 
auricle).  Examine  the  left  ventricle  as  to  its  size,  the  thick- 
ness of  its  walls,  the  appearance  of  the  cut  surface  of  the 
muscle.  Note  the  colour  of  the  muscle.  Look  for  fatty 
change,  more  especially  in  the  papillary  muscles,  for  fibrous 
tissue  (indicating  the  existence  of  chronic  interstitial  myo- 
carditis), more  particularly  towards  the  apex  of  the  ventricle, 
in  the  interventricular  septum,  and  in  the  incised  papillary 
muscles.  Estimate  the  consistence  of  the  muscle  by  testing 
its  friability. 

Now  examine  the  mitral  valve  as  to  its  diameter.  The 
opening  normally  admits  two  digits.  Look  for  thickening  of 
the  segments  and  of  the  chordae  tendineae,  for  vegetations  on 
its  surface  or  fatty  change  in  the  endothelium. 

Then  turn  to  the  aortic  valve,  estimate  its  circumference. 
Look  for  thickening,  calcification,  vegetations.  Examine  the 
portion  of  the  aorta  still  attached  for  atheroma.  Lastly,  look 
at  both  coronary  arteries,  more  especially  the  left,  for  the 
presence  of  dilatation  or  narrowing,  for  fatty  or  calcareous 
atheroma,  and  for  thrombosis. 


HEART  WEIGHTS  AND  MEASUREMENTS 

Weight,  9-13  oz.  (250-370  grammes). 
Length  of  left  ventricle,  3-3  J  in.  (7-6-8-4  cm.). 
Thickness  of  wall  of  left  ventricle,  \  in.  (at  thinnest)  to  J  in. 
(-6-1-2  cm.). 

Length  of  right  ventricle,  3^  to  3§  in.  (7-8-8-6  cm.). 
Thickness  of  wall  of  right  ventricle,  ^  in.  (0-32  cm.). 


76  DISEASES  OF  THE  HEART  AND  PERICARDIUM 


DIAMETERS  AND  CIRCUMFERENCES  OF  THE  HEART  VALVES 
(Shennan) 


Diameters. 

Circumferences. 

Tricuspid 

:  .       .       ins. 
cm. 

1-5  to  1-8 
3-8  to  4-7 

4-5  to    5-5 
11-4  to  14-0 

Pulmonary    . 

ins. 
cm. 

I-I   tO  1-2 

2-8  to  3-0 

3-4  to    3-7 
8-6  to    9-5 

Mitral     . 

ins. 

1-2  to  i  -4 

3-7  to    4-4 

cm. 

3-o  to  3-5 

9'5  to  ii-o 

Aortic     . 

ins. 
cm. 

0-9  to  i-o 
2-3  to  2-5 

2-8  to    3-2 
7-2  to    8-0 

CHAPTER  V 

DISEASES   OF  THE  VESSELS 

THESE  may  be  divided  into  (A)  Diseases  of  the  Arteries, 
(B)  Diseases  of  the  Veins. 

A.  DISEASES  OF   THE  ARTERIES 

In  all  cases  of  sudden  death  the  arteries  of  the  internal 
organs  should  be  slit  up  and  carefully  examined  for  the 
presence  of  impacted  emboli.  More  particularly  is  this  the 
case  with  the  pulmonary  and  coronary  arteries. 

In  cases  of  senile  gangrene  the  vessels  of  the  affected  limb 
should  be  opened  up  and  thrombi  or  impacted  emboli  sought 
for. 

Amyloid  or  Waxy  Degeneration. — This  is  a  condition 
which  usually  starts  in  the  arterioles,  particularly  those  of 
the  internal  organs — spleen,  kidney,  liver,  intestine — and 
spreads  forwards  to  the  capillaries  and  backwards  to  the 
larger  vessels.  In  the  case  of  the  medium-sized  vessels  the 
change  occurs  in  the  middle  coat,  affecting  the  bands  of 
connective  tissue  which  lie  between  the  circular  muscle 
fibres.  The  condition  is  only  found  on  microscopic  examina- 
tion, although  by  means  of  iodine,  when  advanced,  it  may 
be  made  visible  to  the  naked  eye.  With  iodine  the  affected 
area  gives  a  mahogany  brown  colour.  Amyloid  degeneration 

77 


78  DISEASES  OF  THE  VESSELS 

should  be  looked  for  especially  in  (i)  advanced  tuberculosis, 
(2)  visceral  syphilis,  (3)  chronic  suppuration,  e.g.  long- 
existent  empyema,  bone  disease,  etc. 

Fatty  Degeneration  of  the  Intima.  —  This  may  be 
seen,  more  particularly  in  the  aorta,  in  the  form  of  pale 
yellow  streaks  or  patches  often  arranged  in  the  long  axis  of 
the  vessel.  It  is  associated  with  anaemia  and  toxaemias. 

Microscopically,  the  fatty  change  is  found  in  the  endothelial 
cells  and  in  the  subendothelial  connective  tissue. 

Calcareous  Degeneration  of  the  Media. — This  is  a 
change  found  chiefly  in  old  age.  It  may  be  preceded  by 
fatty  or  hyaline  change,  and  it  affects  the  medium-sized 
arteries,  such  as  the  femoral,  brachial,  and  radial.  The 
arteries  which  are  the  seat  of  the  change  are  hard  and  brittle 
and  show  a  transverse  striping  very  noticeable  to  the  naked 
eye. 

Acute  Inflammation. — This  may  occur  in  the  first  part 
of  the  aorta  due  to  extension  of  inflammation  from  aortic 
endocarditis  of  the  ulcerative  form.  It  may  occur  in  arteries 
passing  through  areas  which  are  the  seat  of  acute  inflam- 
matory change.  More  frequently  it  is  caused  by  the 
impaction  of  an  embolus  containing  germs,  which  sets  up 
inflammation  in  the  wall  of  the  vessel  and  may  lead  to  the 
formation  of  an  acute  aneurysm,  e.g.  in  a  branch  of  the 
pulmonary  artery. 

ARTERIOSCLEROSIS 

Arteriosclerosis,  or  hardening  of  the  arteries,  is  an 
exceedingly  common  condition,  and  as  defined  includes  a 
number  of  diseases  of  somewhat  different  nature  and  origin. 
The  calcareous  degeneration  of  the  media  already  mentioned 
is  one  type.  Another  type  is  endarteritis  deformans, 
atheroma,  or,  as  it  has  more  recently  been  called,  athero- 
sclerosis. Another  type  is  syphilitic  disease  of  arteries. 


DISEASES  OF  THE  VESSELS  79 

Lastly,  there   is   hypertrophy  of  the   middle  coat  of  the 
medium-sized  and  smaller  vessels. 
Types  of  arteriosclerosis. 

1.  Atheroma,  atherosclerosis,  endarteritis  deformans. 

2.  Hypertrophy  of  the  media. 

3.  Endarteritis  obliterans. 

4.  Calcareous  degeneration  of  the  media  (see  above). 


Atheroma  (Gr.  d^/or/,  porridge),  Atherosclerosis, 
Endarteritis  Deformans 

A  nodular  and  a  diffuse  form  of  the  condition  are 
sometimes  distinguished,  the  former  affecting  the  aorta, 
the  coronary,  pulmonary,  and  cerebral  arteries,  the  latter 
more  associated  with  the  medium-sized  and  smaller  vessels, 
such  as  the  renal  and  its  branches,  the  radial,  and  some- 
times the  coronary  and  cerebral.  The  nodular  form  is, 
however,  not  infrequently  found  in  the  smaller  vessels 
mentioned. 

In  the  aorta  the  condition  appears  first  as  streaks  or 
patches  of  a  grey  or  pearly  white  appearance,  slightly  raised 
above  the  surface,  and  due  to  thickening  of  the  intima.  These 
patches  occur  especially  round  the  openings  where  smaller 
branches,  such  as  the  intercostals,  leave  the  main  trunk, 
also  in  the  arch  of  the  aorta.  Very  early  in  their  formation 
they  become  opaque  and  yellow  in  colour  owing  to  fatty 
change.  The  patches  gradually  increase  in  size,  and  eventually 
become  the  seat  of  a  calcareous  deposit,  thus  forming  hard 
brittle  plates  in  the  intima  of  the  vessel  (Fig.  28).  The  intima 
then  tends  to  degenerate  and  disappear,  leaving  a  cavity,  the 
floor  of  which  is  formed  of  pulpy  necrotic  material — the 
atheromatous  ulcer.  Thrombosis  may  occur  on  the  diseased 
area  even  before  the  formation  of  the  ulcer.  There  is  an 
increased  tendency  to  it  after  the  ulcer  has  developed.  When 
well  marked,  the  change  is  often  found  throughout  the  entire 


8o  DISEASES  OF  THE  VESSELS 

length  of  the  aorta — thoracic  and  abdominal.  It  tends  to 
be  more  advanced  in  the  arch  and  in  the  lower  part  of  the 
abdominal  aorta  just  before  it  bifurcates.  Similar  changes 
are  to  be  seen  in  the  larger  branches  and  in  the  medium- 
sized  vessels,  such  as  coronaries,  cerebrals,  etc.  The  patchy 
character  of  the  disease  is  often  particularly  well  seen  in  the 
vessels  of  the  brain  (Fig.  29),  where,  owing  to  their  transpar- 
ency, the  yellow  areas  can  be  seen  even  in  the  smaller  branches. 
In  these  medium-sized  and  smaller  vessels,  such  as  cerebral 
and  coronary,  the  thickening  of  the  intima  often  leads  to 
very  marked  narrowing  of  the  lumen. 

A  special  type  of  atheroma,  termed  syphilitic,  may  be 
distinguished.  It  is  frequently  combined  with  true  atheroma. 
In  position,  however,  it  is  found  especially  in  the  first 
part  of  the  aorta,  often  spreading  to  and  involving  the 
segments  of  the  aortic  valve,  thus  leading  to  aortic 
incompetence.  Whereas  atheroma  is  a  disease  of  more 
advanced  age,  this  type  is  often  found  in  comparatively 
young  people.  It  may  not  always  be  syphilitic  in  origin,  but 
in  many  cases  it  undoubtedly  is  so,  spirochsetes  having  been 
found  in  the  lesions  in  the  vessel  wall.  This  type  is  char- 
acterised by  the  formation  of  large,  white,  raised,  semi-trans- 
lucent or  opaque  white  patches.  There  is  not  the  same  tendency 
to  fatty  and  calcareous  change,  so  that  the  patches  remain 
white  and  there  is  no  formation  of  atheromatous  ulcers. 
Puckering  not  infrequently  occurs  in  the  centres  of  these 
areas. 

Effects  of  Atheroma. 

(1)  Loss  of  power  of  the  vessel  to  dilate  and  contract. 

(2)  Narrowing  of  lumen  of  vessel,  with  tendency  to  de- 
generative changes  in  organ  or  tissue  supplied,  with  replace- 
ment of  functioning  cells  by  fibrous  tissue.     In  kidney — 
chronic  interstitial  nephritis ;    in  heart — chronic  interstitial 
myocarditis. 

(3)  As  a  result  of  narrowing  of  the  lumen  there  is  increased 


DISEASES  OF  THE  VESSELS  81 

difficulty  in  driving  the  blood  along,  hence  hypertrophy  of 
the  left  ventricle  occurs, 

(4)  Weakening  of  the  vessel  wall,  with  tendency  to  dilate 
at  some  point  and  form  an  aneurysm  with  tendency  also  to 
rupture. 

(5)  Tendency  to  thrombosis  on  the  diseased  areas,  with 
consequent  tendency  to  embolism. 

Microscopically^  the  earliest  change  is  found  to  be  a  pro- 
liferation of  the  subendothelial  connective-tissue  cells.  This 
leads  to  a  thickening  of  the  intima  formed  of  layers  of  rounded 
and  spindle-shaped  connective -tissue  cells  with  intercellular 
fibrils.  Owing  to  the  fact  that  the  nourishment  of  the  intima 
and  of  the  inner  portion  of  the  media  is  obtained  from  the 
blood  circulating  within  the  vessel  itself,  the  deeper  portions 
of  the  thickened  intima  undergo  fatty,  and  eventually  calcareous, 
change.  Fatty  globules  and  crystals  of  fatty  acids  are  found  in 
the  degenerated  area,  also  granules  of  calcium  salts.  Changes 
are  also  to  be  observed  in  the  internal  elastic  lamina.  It 
splits  into  fine  fibrils  and  becomes  fragmented.  This  damage 
to  the  internal  elastic  lamina  is  regarded  generally  as  the 
primary  change.  The  media  may  also  show  fatty  degeneration, 
owing  to  interference  with  its  nourishment.  It  not  infrequently 
gives  way,  and  the  vessel  becomes  dilated. 

In  the  case  of  the  aorta  the  changes  in  the  media  may  be 
more  marked.  There  may  be  invasion  of  vessels  from  the 
vasa  vasorum  into  the  media,  and  around  these  vessels  there 
are  numerous  round  cells. 

In  the  syphilitic  type,  in  addition  to  the  greatly  thickened 
intima  composed  of  layers  of  well-formed  fibrous  tissue  without 
fatty  or  calcareous  change,  there  is  marked  change  in  the 
media.  This  takes  the  form  of  an  invasion  of  the  media  by 
vessels  accompanied  by  connective  tissue.  This  results  in  a 
replacement  of  the  media  by  fibrous  scar  tissue,  the  contraction 
of  which  causes  the  puckerings. 

Causation. — During  the  first  twenty  years  of  life  there  is 
a  progressive  thickening  of  the  coats  of  the  vessels  with  a 
progressive  development  of  elastic  tissue.  For  the  next 
twenty  years  of  life  approximately  things  remain  stationary. 

6 


82  DISEASES  OF  THE  VESSELS 

After  that  there  is  a  progressive  deterioration  in  the  elastic 
tissue,  with  consequent  weakening  of  the  vessel  wall.  In 
certain  individuals  the  elastic  tissue  of  the  vessels  is  congenially 
deficient.  Atheroma  is  a  disease  which  develops  at  the  time 
of  life  when  the  vessels  are  beginning  to  deteriorate,  but  the 
individual  is  at  the  height  of  his  physical  activities.  High 
blood  pressure  from  bodily  exertion,  combined  with  degenerat- 
ing elastic  tissue,  are  the  two  main  factors  in  the  disease. 
Sometimes  the  one,  sometimes  the  other  is  the  more  prominent. 
That  high  pressure  of  itself  can  produce  the  condition  is 
proved  by  the  experimental  work  on  animals.  By  the 
administration  of  doses  of  adrenalin  over  periods  of  weeks 
and  months,  thus  causing  contraction  of  the  vessels  and 
raising  the  blood  pressure,  it  has  been  found  possible  to 
produce  changes  in  the  vessels  of  rabbits  analogous  to 
atheroma  in  the  human  subject.  The  same  thing  has  been 
effected  by  holding  the  animal  up  by  the  hind  legs  for  a  few 
minutes  every  day  for  some  weeks.  In  this  way  well- 
marked  degenerative  changes  very  similar  to  human  atheroma 
have  been  produced  in  the  vessels  above  the  diaphragm. 

Infective  conditions  such  as  syphilis  act  by  causing  pro- 
liferative  changes  of  an  inflammatory  nature  in  the  intima. 
As  a  result  there  is  malnutrition  of  the  vessel  wall  subjacent  to 
the  thickened  area  with  consequent  degenerative  changes. 

In  the  human  subject  toxic  conditions  associated  with  high 
blood  pressure,  such  as  renal  disease,  lead  poisoning,  gout, 
alcoholic  poisoning,  are  also  factors  in  the  production  of  the 
disease.  At  the  same  time,  infective  conditions  such  as 
syphilis  cannot  be  ignored. 

As  to  the  nature  of  the  primary  change,  this  is  generally 
regarded  as  being  a  fragmentation  and  fibrillation  of  the 
internal  elastic  lamina.  Subsequent  to  this,  and  with  a  view 
to  repairing  the  damage,  there  is  a  proliferation  of  the  cells 
of  the  intima,  with  resultant  thickening.  Owing  to  the  fact 
that  the  intima  and  outer  portion  of  the  media  obtain  their 
nourishment  from  the  blood  flowing  in  the  vessel  itself,  the 
deeper  portion  of  this  new  tissue  and  the  adjacent  media 
undergo  degeneration  of  a  fatty  nature.  The  fatty  acids 
which  are  formed  are  believed  to  combine  with  alkalies  to 
form  soaps.  Among  these  soaps  are  calcium  combinations. 
The  fatty  acid  is  rejected  by  the  calcium  in  favour  of  carbonic 


DISEASES  OF  THE  VESSELS  83 

and    phosphoric   acid,   with    resulting    deposition   of  calcium 
carbonate  and  phosphate  in  a  granular  form. 

Summary  of  Causes  of  Atheroma. 

(1)  Old  age. 

(2)  Congenital  deficiency  in  elastic  tissue  of  vessels. 

(3)  Strain. 

(4)  Chronic  toxaemias — alcohol,  gout. 

(5)  Infective  conditions — syphilis. 

Hypertrophy  of  the  Media. 

This  is  another  form  of  arteriosclerosis  due  to  contrac- 
tion under  prolonged  stimulation  by  the  influence  of  toxic 
substances  circulating  within  the  vessel.  It  is  very  character- 
istically associated  with  the  subacute  and  chronic  forms  of 
Bright's  disease.  The  condition  affects  the  medium-sized 
and  smaller  vessels.  The  hypertrophy  of  the  muscular  coat 
is  followed  by  a  fibrous  transformation. 

Endarteritis  Obliterans  or  Proliferans 

This  is  a  type  of  arterial  disease  associated  with  thickening 
of  the  intima  in  which  there  is  no  tendency  to  degenerative 
change,  as  in  atheroma.  The  reason  is  that  the  new  tissue  laid 
down  within  the  internal  elastic  lamina  carries  with  it  its 
own  blood-vessels.  This  tissue  is,  in  other  words,  granulation 
tissue.  The  condition  is  found  associated  with  all  types  of 
chronic  inflammation,  e.g.  tuberculosis,  syphilis,  leprosy. 
It  is  usually  regarded  as  being  specially  significant  of  the 
presence  of  syphilitic  disease,  but  it  is  just  as  frequent  in 
tuberculosis.  It  is  found  in  the  vessels  in  the  neighbourhood 
of  syphilitic  gummata  and  in  vessels  in  the  lung,  bones  and 
joints  in  tuberculosis.  Sometimes  it  occurs  in  the  vessels 
of  the  brain  in  syphilis,  thrombosis  in  these  vessels  in  early 
life  being  a  not  infrequent  cause  of  cerebral  paralysis.  In 
the  lung  in  tuberculosis  the  change  is  a  most  beneficial  one, 
as  the  tendency  to  rupture  of  vessels  in  the  neighbourhood 
of  cavities  is  thereby  greatly  diminished.  It  is  probable 


84  DISEASES  OF  THE  VESSELS 

that  the  atrophy  of  limbs  in  tuberculous  joint  and  bone 
affections  may  in  part  be  explained  by  malnutrition  following 
diminution  in  size  of  lumen  of  the  nourishing  vessels.  As 
might  be  anticipated,  the  change  is  often  accompanied  by 
inflammation  of  the  other  coats  of  the  vessel,  more  especially 
the  adventitia. 

Microscopically^  the  condition  is  characterised  by  the  laying 
down  of  layers  of  new  tissue  within  the  internal  elastic  lamina. 
At  first  the  tissue  is  cellular,  later  on  it  becomes  well-developed 
connective  tissue.  Very  often  new  layers  of  elastic  tissue  are 
formed,  and  sometimes  there  are  several  small  vessels  within 
the  compass  of  the  original  vessel  wall.  In  addition,  there 
are  inflammatory  changes  in  media  and  adventitia,  more 
especially  the  latter. 

Arterial  Disease  in  Syphilis.  —  Syphilis  affects  the 
arteries  in  several  ways.  It  is  one  of  the  infective  conditions 
leading  to  atheroma,  more  especially  to  that  type  called 
syphilitic,  where  the  aorta  is  the  seat  of  formation  of  raised, 
white,  semi-translucent  areas  with  a  tendency  to  puckering. 

Another  type  of  lesion  found  more  especially  in  the  smaller 
arteries  is  the  above-mentioned  endarteritis  obliterans,  with 
accompanying  periarteritis. 

Syphilitic  disease  of  vessels  is  a  frequent  cause  of  aneurysm 
formation  and  of  thrombosis. 

Arterial  Disease  in  Tuberculosis. — Tuberculous  disease 
has  a  marked  tendency  to  spread  by  the  perivascular  lymph- 
atics, and  thus  has  from  the  commencement  an  intimate 
association  with  vessels.  This  condition  of  periarteritis 
leads  to  a  thickening  of  the  vessel.  The  process  may  spread 
inwards  and  produce  an  endarteritis.  Sometimes  a  tuber- 
culous focus  may  burst  its  way  through  a  vessel  wall,  thus 
giving  rise  to  a  general  blood  infection. 

This  endarteritis  is  found  in  a  marked  degree  in  all  cases 
of  chronic  pulmonary  tuberculosis.  It  is  also  found  in 
the  smaller  vessels  in  the  neighbourhood  of  tuberculous 


DISEASES  OF  THE  VESSELS  85 

lesions  of  bones  and  joints.  As  in  syphilis  the  thickened 
intima  shows  no  tendency  to  degeneration  in  its  deeper 
parts. 

The  inflammatory  change  in  the  vessel  walls  in  the  neigh- 
bourhood of  cavities  may  lead  to  weakening,  aneurysm 
formation,  or  rupture.  As  previously  stated,  it  more  fre- 
quently causes  more  or  less  complete  obliteration. 

Aneurysm 

An  aneurysm  is  a  localised  enlargement  of  the  lumen  of 
an  artery.  The  enlargement  may  involve  the  whole  lumen 
for  a  short  distance  (fusiform  aneurysm) ,  or  it  may  be  a 
diverticulum  from  one  side  of  the  vessel  (saccular  aneurysm) 

(Fig.  31)' 

The  term  acute  aneurysm  is  applied  to  any  rapid  dilatation 
of  an  artery  through  an  inflammatory  process  in  its  wall, 
usually  due  to  the  presence  of  a  septic  thrombus  within 
its  lumen.  A  false  aneurysm  is  an  accumulation  of  blood 
communicating  with  a  vessel  and  surrounded,  not  by  the 
vessel  wall,  but  by  a  condensation  of  tissue  in  the  neighbour- 
hood. A  dissecting  aneurysm  is  a  condition,  found  usually 
in  the  aorta,  where  the  blood  finds  its  way,  commonly  by  a 
split  in  a  calcareous  atheromatous  patch,  between  the  intima 
and  media,  or  between  media  and  adventitia,  or  again  between 
two  layers  of  media.  Sometimes  the  blood  finds  its  way  back 
again  at  a  different  level  into  the  lumen.  The  term  miliary 
aneurysm  is  applied  to  minute  dilatations,  usually  of  a 
saccular  type,  occurring  on  the  course  of  the  smaller  cerebral 
arteries. 

The  most  common  site  for  aneurysm  is  the  thoracic  aorta — 
the  ascending  portion,  the  arch  or  descending  portion.  The 
next  most  common  site  is  the  abdominal  aorta,  then  come 
the  popliteal  and  carotid  arteries.  The  special  type,  miliary 
aneurysm,  is  found  in  the  cerebral  vessels.  Aneurysms  also 
occur  in  the  branches  of  the  pulmonary  artery  in  the  neigh- 


86  DISEASES  OF  THE  VESSELS 

bourhood  of  tuberculous  cavities  (Fig.  52),  and  as  the  result 
of  septic  embolism. 

Aneurysms  vary  greatly  in  size  and  shape.  The  cavity 
may  be  largely  filled  with  white  and  red  thrombus,  often 
with  a  laminated  appearance.  This  thrombus  is  seldom 
the  seat  of  organisation.  The  wall  may  be  formed  of  all 
the  coats  of  the  vessel.  Usually,  however,  the  intima,  if 
present  at  all,  is  in  patches.  This,  no  doubt,  is  the  explana- 
tion of  the  non-occurrence  of  organisation  in  the  thrombus 
contents.  The  media  may  also  disappear  and  the  wall  be 
formed  only  of  adventitia  and  condensed  connective  tissue 
surrounding.  Occasionally  the  wall  is  partly  formed  of  bony 
structures  such  as  the  vertebrae  (Fig.  31).  The  wall  of  the 
vessel  in  the  neighbourhood  is  usually  the  seat  of  athero- 
matous  change,  frequently  of  the  syphilitic  type. 

Changes  produced  in  Surrounding  Parts. — These  depend 
upon  the  position  of  the  aneurysm.  The  dilating  vessel 
presses  upon  viscera,  such  as  trachea,  bronchi,  oesophagus, 
upon  nerves  and  vessels.  Thus  irritation  or  paralysis  of 
nerves — recurrent  laryngeal,  trunks  of  the  brachial  plexus — 
results.  Pressure  on  trachea  and  bronchi  leads  to  accumula- 
tion of  secretion,  and  sometimes  to  gangrene  of  the  lung,  also 
to  erosion  and  rupture.  Pressure  on  oesophagus  similarly 
causes  obstruction,  and  may  result  in  rupture.  Bones  such 
as  sternum  and  vertebrae  are  eroded,  also  cartilage,  but  the 
softer  the  tissue  the  better  it  resists,  so  that  intervertebral 
discs  may  project  beyond  the  harder  bone.  Pressure  upon 
lung  leads  to  collapse  and  atrophy. 

Smaller  vessels  arising  from  the  aneurysmal  portion  of  the 
vessel  tend  to  be  contorted,  and  sometimes  their  lumen 
obstructed  by  thrombus.  The  heart  may  be  displaced 
downwards,  and  may  be  hypertrophied. 

Rupture  may  occur  through  the  skin  in  thoracic  aneurysm, 
projecting  forwards,  into  the  trachea,  bronchi,  oesophagus, 
per icar dial  sac,  pulmonary  artery.  In  the  case  of  cerebral 


DISEASES  OF  THE  VESSELS  87 

aneurysms,  into  the  brain  substance  or  under  the  membranes ; 
in  phthisical  aneurysms,  into  the  lung  cavity,  with  con- 
sequent haemoptysis. 

Causation. — Two  factors  are  concerned  in  the  causation. 

(1)  Conditions  which  lead  to  weakening  of  the  vessel  wall, 
(a)  injury  as  from  a  gunshot  wound,  (b)  disease,  such  as  (i.) 
acute  arteritis  from  inflammation  around  the  vessel  or  from 
impaction  of  a  septic  embolus  in  the  vessel,  (ii.)  chronic 
arteritis    from    atheroma,   more    especially   the    syphilitic 
type. 

(2)  Conditions  leading  to  sudden  rise  of  blood  pressure, 
e.g.  lifting  of  heavy  weights. 

The  condition  is  far  more  frequent  in  males  than  in  females 
(out  of  189  cases,  171  males).  It  occurs  as  a  rule  above  forty 
years  of  age,  i.e.  at  the  period  when  the  vessels  are  beginning 
to  degenerate  while  the  individual  is  still  in  active  work.  In 
something  over  50  per  cent  of  cases  a  history  of  syphilis  may 
be  obtained. 


B.  DISEASES  OF  VEINS 

Thrombosis  occurs  in  veins  where  the  blood  current  is 
slowed  from  dilatation  and  varicosity.  In  all  probability  in 
addition  there  must  be  some  inflammatory  condition  of  the 
vessel  wall  leading  to  damage  of  the  endothelium.  The 
condition  may  be  found  in  any  vein  where  walls  are  inflamed. 
Thus  the  small  venous  radicles  in  the  neighbourhood  of  any 
inflammatory  focus  tend  to  undergo  thrombosis.  When 
organisms  invade  such  thrombi  and  soften  and  break  them 
down,  portions  of  the  thrombus  containing  germs  are  apt  to 
be  carried  away  by  the  blood  current  and  deposited  in  distant 
organs.  The  liver  is  affected  when  the  rootlets  of  the  portal 
vein  are  thrombous ;  the  lung,  in  the  case  of  other  venous 
radicles,  becomes  the  seat  of  septic  embolism  and  abscess 
formation  (see  diagram,  p.  62). 


88  DISEASES  OF  THE  VESSELS 

Thrombosis  once  started  tends  to  spread.  Not  infre- 
quently the  change  begins  in  the  pouch  of  a  valve.  The 
thrombus  grows  until  it  blocks  the  lumen  of  the  vessel.  Then 
the  blood  current  being  stopped,  thrombosis  occurs  in  the 
vessel  up  to  the  next  large  branch.  Subsequently  another 
slow  thrombotic  process  starts,  until  again  the  vessel  is 
blocked.  In  this  way  the  process  initiated  in  a  small  rootlet 
of  the  femoral  vein  may  pass  up  as  far  as  the  inferior  vena 
cava. 

Thrombi  in  veins  may  become  organised  and  may  lead  to 
obliteration  of  the  vessel.  Or  they  may  be  the  seat  of 
deposit  of  calcareous  material  forming  so-called  phleboliths. 
Again,  sometimes  the  thrombus  in  course  of  organisation  may 
be  tunnelled  and  the  circulation  re-established. 

Two  types  of  thrombi  are  distinguished  according  to 
their  colour,  (a)  red,  (b)  white.  Red  thrombi  form  when 
the  blood  is  suddenly  brought  to  a  standstill,  white  thrombi 
are  formed  when  the  blood  is  in  motion. 

Thrombi  in  veins  not  infrequently  undergo  softening. 
Two  types  of  softening  are  distinguished  :  (a)  simple  soften- 
ing ;  (b)  septic,  due  to  the  action  of  germs. 

Microscopically ',  thrombi  consist  of  the  blood  elements  (red 
corpuscles,  white  cells,  and  blood  platelets)  in  varying  pro- 
portion, bound  together  by  filaments  of  fibrin. 

(a)  In  the  case  of  red  thrombi  the  predominant  element  is 
the  red  blood  corpuscle.     There  are  a  few  white  cells,  and 
between  the  cell    elements  filamentous  and    granular  fibrin. 
Sometimes  the  red  cells  stain  well,  at  other  times  they  have 
lost  their  characteristic  staining  reaction  and  only  their  outlines 
are  visible. 

(b)  In  white  thrombi  leucocytes,  platelets,  and  fibrin  pre- 
dominate.    Organisation  is  frequently  seen.     The  first  stage 
in  the  process  is  a  covering  over  of  the  thrombus  with  a  layer 
of  spindle-shaped  endothelial  cells  from  a  proliferation  of  those 
lining  the  vessel.     Then  from   the   subendothelial  and  other 
connective-tissue  layers,  young  connective-tissue  cells  emigrate 


DISEASES  OF  THE  VESSELS  89 

into  the  thrombus.  They  appear  as  rounded  mononuclear 
cells  to  begin  with  ;  later  on  they  become  spindle-shaped.  At 
the  same  time  the  endothelial  cells  of  the  vasa  vasorum  pro- 
liferate, forming  buds  of  vessels  which  penetrate  the  thrombus. 
Both  these  processes  occur  at  points  where  the  thrombus  is  in 
contact  with  the  vessel  wall.  Elsewhere  the  endothelium 
covering  the  thrombus  develops  buds  which  penetrate  the 
substance  of  the  coagulum  and  become  rilled  with  blood  from 
the  original  lumen.  Subsequently  these  various  blood  channels 
unite  with  one  another,  become  enlarged,  and  thus  the 
thrombus  becomes  tunnelled.  During  the  process  of  organisa- 
tion, pigment  (haematoidin)  granules  are  deposited  in  large 
numbers  in  the  cells. 

Dilatation  and  Varicosity. — This  is  a  condition  which 
is  found  more  especially  in  the  superficial  veins  of  the  lower 
limbs,  in  the  veins  of  the  scrotum  (varicocele),  rectum 
(haemorrhoids),  and  oesophagus. 

As  regards  causation  there  is  undoubtedly  a  tendency  to 
the  condition  in  certain  individuals  owing  to  a  congenital 
weakness  in  the  elastic  tissue  of  the  vessel  wall.  The  condi- 
tion is  aggravated  by  gravity.  It  may  also  be  caused  by 
obstruction  to  the  return  of  the  blood  by  the  wearing  of  tight 
garters,  by  the  presence  of  a  tumour  or  hard  faecal  masses 
pressing  on  the  iliac  veins,  or  by  a  cirrhotic  liver  interfer- 
ing with  the  flow  of  blood  through  the  portal  veins,  and 
affecting  more  especially  the  rootlets  from  the  rectum  and 
oesophagus. 

The  veins  which  are  the  seat  of  the  change  are  dilated 
and  tortuous.  Their  walls  are  thickened  and  there 
may  be  thrombosis  within  them.  Ulceration  from  skin, 
oesophagus,  or  rectum  may  lead  to  erosion  and  consequent 
haemorrhage. 

Phlebitis,  or  inflammation  of  the  wall  of  a  vein,  may  be 
due  to  injury,  or  to  an  inflammatory  focus  in  the  neighbour- 
hood of  a  vein,  as  in  appendicitis,  osteomyelitis,  erysipelas. 
It  may  also  occur  in  syphilis  and  in  gout.  The  condition  is 


go  DISEASES  OF  THE  VESSELS 

always  associated  with  more  or  less  thrombosis  or  clotting  of 
the  blood  within  the  vessel. 

Results. — Obliteration  of  the  vein,  washing  away  of  portions 
of  thrombi,  and  so  formation  of  emboli,  reabsorption,  or 
tunnelling. 


CHAPTER.  VI 

DISEASES   OF  THE   BLOOD,   BONE   MARROW,   LYMPH   GLANDS, 
SPLEEN,   AND   DUCTLESS   GLANDS 

DISEASES  OF  THE  BLOOD 

ALTHOUGH  it  is  unquestionably  better  to  examine  the  blood 
during  the  life  of  the  patient,  it  is  still  possible  to  do  so  after 
death.  The  ease  with  which  this  can  be  done  depends  to  a 
great  extent  upon  how  far  the  blood  has  coagulated  within 
vessels  and  heart.  There  is,  however,  in  blood  diseases,  such 
as  anaemias  and  leukaemias,  a  tendency  for  the  blood  to 
remain  fluid  so  that  films  may  often  be  readily  obtained 
either  from  heart  blood  or  vessels. 

(For  the  bacteriological  examination  of  the  blood,  see  p.  359). 

Septicaemia  and  Pyaemia.  —  Micro-organisms  enter  the 
blood  in  many  infective  conditions.  In  fact,  in  most  acute 
infective  diseases  the  causal  organism  can  be  cultivated 
from  the  blood  at  some  period.  Even  in  the  more  chronic 
forms,  such  as  tuberculosis,  germs  can  be  detected  in  the 
blood  in  a  considerable  proportion  of  cases.  Such  con- 
ditions, in  which  living  organisms  are  circulating  in  the 
blood-stream,  are  usually  known  as  septiccemias.  Formerly 
the  term  was  somewhat  restricted  in  its  use ;  now  it  may 
be  applied  to  a  large  number  of  acute  infective  processes 

91 


92  DISEASES  OF  THE  BLOOD 

including  typhoid  fever  and  pneumonia.  In  the  human 
subject  the  germs  are  almost  never  present  in  numbers 
sufficient  for  their  demonstration  readily  in  stained  blood 
films.  Concentration  or  cultural  methods  have  to  be  adopted 
before  their  presence  can  be  detected.  On  the  other  hand, 
the  same  germs  may,  when  introduced  into  one  of  the  lower 
animals,  give  rise  to  a  condition  in  which  immense  numbers 
of  film  organisms  can  be  demonstrated  microscopically  in  the 
blood.  This  is  notably  the  case  with  the  pneumococcus  and 
the  anthrax  bacillus. 

The  organisms  may  enter  the  blood,  in  the  case  of  the 
smaller  blood-vessels,  through  an  intact  vessels'  wall.  In 
other  instances  an  abscess  or  similar  infective  focus  (in 
tuberculosis  a  caseous  focus)  may  rupture  directly  into  the 
blood-stream,  it. may  be  into  a  vessel  of  considerable  size, 
usually  a  vein.  In  a  majority  of  instances,  in  the  more  acute 
infective  diseases,  the  actual  invasion  of  the  vessel  is  pre- 
ceded by  a  thrombosis  within  the  lumen ;  the  thrombus 
then  becomes  infected  with  germs,  and  portions  of  the  infected 
clot  are  carried  to  other  parts  of  the  body,  there  to  set  up 
metastatic  inflammatory  foci,  or  abscesses.  This  condition 
of  invasion  of  the  blood-stream  by  organisms  plus  the  forma- 
tion of  metastatic  abscesses  is  usually  known  as  pycemia. 

The  primary  focus  from  which  the  infection  of  the  blood 
originates  varies  very  much.  It  may  be  the  intestine  as  in 
typhoid  fever,  the  organism  probably  reaching  the  blood  by 
way  of  the  lymphatics.  It  may  be  the  lung  as  in  acute  lobar 
pneumonia,  the  organisms  passing  directly  from  the  alveoli 
into  the  pulmonary  capillaries.  In  the  conditions  more 
usually  characterised  by  the  term  septicaemia,  it  is  commonly 
a  suppurative  focus  in  the  throat,  appendix,  bone  (in  osteo- 
myelitis), or  an  endocarditis  of  the  malignant  or  ulcerative 
type. 

When  secondary  suppurative  foci  develop  these  may  be 
found  in  kidneys,  liver,  brain,  or  indeed  in  any  part  of  the 


DISEASES  OF  THE  BLOOD  93 

body  in  the  case  of  an  ulcerative  endocarditis,  in  the  lungs 
most  commonly  in  the  case  of  an  osteomyelitis,  in  the  liver 
in  the  case  of  the  appendix  (portal  pyaemic  type  of  liver 
abscess). 

Sometimes  a  condition  may  start  by  being  merely  a 
septicaemia.  Subsequently  it  develops  into  an  ulcerative 
endocarditis  and  pyaemia.  Apparently  organisms  in  the 
blood-stream  have  a  special  tendency  to  become  deposited 
on  the  heart  valves,  especially  such  as  have  already  been 
damaged. 

Both  in  miliary  tuberculosis  and  in  septicaemia  the 
secondary  infective  foci  invade  blood-vessels  in  their  neigh- 
bourhood and  so  further  infect  the  blood-stream  with  germs. 

Pernicious  Anaemia.  —  In  performing  a  post-mortem 
examination  in  a  case  of  this  disease  the  following  changes 
will  be  found  with  a  remarkable  degree  of  constancy. 

The  skin  is  pale,  often  with  a  lemon-yellow  tint  due  to  a 
slight  degree  of  jaundice.  The  subcutaneous  fat  may  be 
considerable  in  amount  and  shows  a  bright  yellow  colour.  In 
examining  the  serous  sacs  minute  haemorrhages  will  be  found, 
more  especially  under  the  visceral  pleura  and  pericardium. 
The  lungs  are  pale  and  show  atrophic  emphysema.  Not 
infrequently  small  haemorrhages  are  found  in  the  substance 
of  the  lungs  as  well  as  under  the  pleura,  and  on  microscopic 
examination  fatty  change  may  be  found  in  the  endothelial 
cells  of  the  vessels.  The  heart  may  be  dilated,  and  is  very 
constantly  the  seat  of  a  fatty  degeneration  of  the  muscular 
substance,  which  is  best  seen  on  the  inner  aspect  of  the  left 
ventricle,  more  especially  on  the  papillary  muscle.  The 
change  is  of  the  patchy  type  described  as  "  thrush  breast 
heart."  The  blood  within  the  heart  cavities  is  often  fluid  and 
always  pale. 

The  liver  is  pale  and  of  a  yellow-brown  colour.  It  shows 
fatty  degeneration  and  a  marked  increase  of  iron-containing 


94  DISEASES  OF  THE  BLOOD 

pigment  (haemosiderin).  This  can  be  demonstrated  by 
pouring  over  the  organ  ferrocyanide  of  potassium  (2  per  cent) 
and  hydrochloric  acid  (i  per  cent),  repeating  the  process 
several  times  if  the  characteristic  "  Prussian  blue  "  colour 
does  not  at  once  appear.  The  pigment  is  present  mainly 
round  the  outer  part  of  each  lobule  (frontispiece,  Fig.  i). 

Microscopic  Appearances. — The  granules  are  found  within 
the  liver  cells  mainly  in  the  outer  two-thirds  of  the  lobule,  and 
also  in  the  endothelial  cells  of  the  vessels.  Necrotic  areas 
are  sometimes  present  in  the  lobules.  In  the  vessels  nucleated 
red  cells  and  endothelial  cells  containing  red  corpuscles  as  well 
as  pigment  granules  are  to  be  found.  Fatty  degeneration  is 
present  in  the  central  part  of  the  lobule. 

The  spleen  is  of  a  dark  brownish-red  colour.  Haemosiderin 
may  be  present  in  sufficient  amount  to  be  demonstrated 
macroscopically.  In  any  case  it  will  be  found  microscopically 
within  the  endothelial  cells  of  the  pulp  sinuses,  which  also 
show  marked  phagocytosis  for  red  blood  corpuscles. 

The  kidney  may  show  nephritis  of  a  catarrhal  or  interstitial 
type.  It  is  very  pale  in  colour  and  often  exhibits  the 
same  Prussian  blue  reaction  as  is  found  in  liver  and  spleen. 

The  mucous  membrane  of  the  stomach  and  intestine  is 
pale,  petechial  haemorrhages  are  often  present,  and  there  is 
atrophy  of  the  mucous  membrane. 

The  bone  marrow  in  the  shafts  of  the  long  bones,  which  is 
normally  of  a  yellow  colour  and  is  composed  of  fat,  is  trans- 
formed into  a  bright  red  marrow  with  a  gelatinous  appearance 
and  consistence. 

Microscopically,  there  is  a  marked  erythroblastic  reaction, 
the  red  cells  showing  evidence  of  active  proliferation.  Many 
of  them  are  of  the  large  nucleated  type  known  as  megaloblasts. 
There  is  also  evidence  of  phagocytic  activity  on  the  part  of 
large  endothelial  cells,  many  of  which  contain  red  blood 
corpuscles. 


DISEASES  OF  THE  BLOOD  95 

Occasionally  in  the  spinal  cord  degenerative  changes,  with 
consequent  sclerosis,  are  found  in  the  posterior  and  postero- 
lateral  columns. 

The  chief  blood  changes  of  pernicious  anaemia  may  be 
briefly  recapitulated.  There  is  marked  diminution  in  the 
number  of  red  blood  corpuscles  (average  count  i-|  millions), 
with  a  less  marked  diminution  in  haemoglobin  (average  40 
per  cent),  so  that  the  colour  index  (the  ratio  of  the  percentage 
of  haemoglobin  to  the  percentage  number  of  corpuscles, 
e.g.  as  above,  |~£)  is  greater  than  unity.  On  the  examination 
of  a  film  of  blood  the  main  change  is  found  to  be  variation  in 
size  of  the  blood  corpuscles  (macrocytes  and  microcytes  being 
present),  with  marked  variation  in  shape  (poikilocytosis). 
Nucleated  red  corpuscles  are  usually  to  be  found,  and  of  these 
the  large  variety  (megaloblast)  predominates  over  the  normo- 
blast.  In  addition,  basophil  granules  are  often  found  scattered 
through  the  corpuscles  (punctate  basophilia  or  granular 
degeneration),  and  not  infrequently  the  red  cell  takes  on  both 
acid  and  basic  dye,  assuming  thus  a  bluish  colour  (poly- 
chromatophilia).  The  leucocytes  are  commonly  reduced  in 
number,  with  a  slight  relative  increase  of  the  lymphocytes. 
The  blood  plates  are  also  fewer  in  number. 

Splenic  Anaemia. — This  term  is  commonly  used  to 
characterise  cases  of  severe,  unexplained  anaemia,  in  which 
splenic  enlargement  is  a  prominent  feature.  Undoubtedly 
a  number  of  different  conditions  have  been  included.  An 
adult  and  an  infantile  type  are  described. 

Under  the  adult  form  the  condition  known  as  Band's 
disease  may  be  classified.  This  is  characterised  by  an  en- 
largement of  the  spleen  with  cirrhosis  of  the  liver  and 
atheroma  of  the  splenic  and  portal  vessels.  Microscopically, 
the  spleen  shows  a  diffuse  fibrosis  both  of  the  Malpighian 
bodies  and  of  the  reticulum.  The  Gaucher  type  of  splenic 
enlargement  also  comes  under  this  heading.  In  it  the  spleen 
is  enormously  enlarged  and  the  parenchyma  is  transformed 


96  DISEASES  OF  THE  BLOOD 

into  spaces  resembling  the  alveoli  of  a  gland.  These  spaces 
are  lined  by  peculiar,  large  mononuclear  cells.  The  liver 
is  also  enlarged  and  contains  groups  of  these  cells.  Similar 
cells  are  also  present  in  the  bone  marrow. 

The  infantile  type  of  splenic  anaemia  has  no  constant 
features.  The  enlarged  spleen  shows  microscopically  a 
general  fibrosis. 

The  blood  pictures  in  splenic  anaemia  are  not  constant  or 
characteristic.  The  general  type  is  that  of  a  secondary 
anaemia  with  a  relatively  excessive  diminution  in  the  per- 
centage of  haemoglobin,  hence  a  low  colour  index.  As  a  rule 
the  leucocytes  are  diminished. 

Leukaemia  (Leucocythemia) 
Two  main  types  of  this  condition  are  recognised  : — 

(1)  Myelocythemia,  myel&mia,  spleno-medullary  leuk&mia. 

(2)  Lymphocytkemia,  lymphcemia,  lymphatic  leukcemia. 

(i)  Myelocythemia. — This  is  a  condition  in  which  there 
is  an  enormous  proliferation  of  leucocytes  and  leucocyte- 
forming  cells,  mainly  of  the  granular  variety,  chiefly  in  the 
bone  marrow.  The  result  is  that  fully  developed  leucocytes 
and  immature  forms  (myelocytes)  overflow  into  the  circula- 
tion in  large  numbers.  The  disease  is  probably  a  tumour 
formation  related  to  the  sarcomata. 

The  blood  is  often  paler  than  normal.  Large  greenish- 
yellow  or  white  clots  may  be  found  in  the  heart  and  vessels. 
Films  show  an  enormous  preponderance  of  white  blood 
corpuscles.  Instead  of  the  normal  proportion  of  i  white 
to  500  reds,  there  may  be  i  to  10,  or  even  i  to  i.  The 
prevailing  types  of  leucocyte  present  are  the  polymorpho- 
nuclear  and  the  neutrophil  myelocyte.  These  latter  are 
very  large  cells,  not  infrequently  20  ^  in  diameter,  with 
large,  pale  nuclei  and  neutrophil  granules  in  their  protoplasm. 
In  addition,  there  is  a  marked  increase  in  the  number  of 
eosinophils,  and  eosinophil  myelocytes  are  also  present  in 


DISEASES  OF  THE  BLOOD  97 

large  numbers.  Mast  cells  (cells  with  basophil  granules)  are 
present,  often  in  great  numbers.  There  are  considerable 
numbers  of  lymphocytes  and  other  hyaline  cells,  but  these 
are  relatively  greatly  diminished.  The  red  cells  are  reduced 
in  number  and  nucleated  red  cells  of  the  normoblast  type 
are  usually  present. 

The  organs  generally  tend  to  be  enlarged  and  have  a  pale 
appearance. 

The  spleen  is  usually  greatly  enlarged  (Fig.  33).  It  may 
weigh  as  much  as  18  Ibs.  The  enlargement  is  uniform,  and 
the  shape  with  the  notches  is  preserved.  The  organ  may  reach 
as  far  down  as  the  pubis.  In  consistence  the  organ  is  firm. 
The  surface  often  shows  chronic  perisplenitis.  Infarcts  are 
very  commonly  present.  On  section,  the  cut  surface  has  a 
uniformly  pale  pink,  flesh-like  appearance.  The  Malpighian 
bodies  are  invisible. 

Microscopic  Appearances. — The  sinuses  of  the  pulp  are 
filled  with  leucocytes  of  the  different  types.  In  addition,  there 
are  numerous  swollen  endothelial  cells,  in  some  of  which  red 
blood  corpuscles  can  be  seen.  There  is  increase  of  fibrous 
tissue  and  pigment,  the  fibrous  tissue  spreading  from  around 
trabeculae  and  vessels.  Malpighian  bodies  are  inconspicuous. 

The  bone  marrow  throughout  the  body  has  a  pale  pink 
colour.  The  marrow  of  the  shafts  of  the  long  bones,  instead 
of  being  fatty,  has  a  similar  pale  pink  appearance. 

Microscopically,  granular  cells  of  all  kinds  are  found  present 
in  greatly  increased  numbers.  There  is  evidence  of  great 
rapidity  of  division  (mitotic  figures)  among  all  types  of  myelo- 
cytes.  Red  cells  are  relatively  few  in  number. 

The  liver  (p.  191)  and  kidneys  (p.  223)  are  enlarged  and 
pale,  and  show  microscopically  more  or  less  infiltration  with 
leucocytic  cells.  The  lymphatic  glands  may  or  may  not  be 
enlarged. 

(2)  Lymphocythemia.— In  this  type  of  the  disease  there 

7 


98  DISEASES  OF  THE  BLOOD 

is  a  proliferation  of  the  leucocytes  of  the  non-granular  or 
hyaline  type.  These  overflow  into  the  blood  and  infiltrate 
the  organs.  The  condition,  like  the  previous,  is  probably 
neoplastic  in  nature. 

The  blood  is  pale,  and  films  show  usually  a  marked  increase 
of  white  corpuscles.  This  is  seldom  so  marked  as  in  the 
previous  type  of  the  disease.  Occasionally  there  is  no 
increase.  The  prevailing  type  of  leucocyte  is  the  lymphocyte, 
large  or  small.  These  form  from  90  per  cent  to  99  per  cent 
of  the  white  corpuscles.  Granular  cells  are  few  and  far 
between.  The  red  blood  cells  are  reduced  in  numbers,  and 
nucleated  corpuscles  are  usually  present. 

The  appearance  of  the  bone  marrow  is  similar  to  that 
found  in  myelocythemia.  But  on  microscopic  examination 
lymphocytes  instead  of  the  granular  cells  predominate. 

The  lymphatic  glands  are  very  commonly  enlarged,  some- 
times attaining  the  size  of  a  hen's  egg. 

Microscopically,  they  are  found  infiltrated  with  immense 
numbers  of  lymphocytes. 

The  spleen  is  usually  enlarged,  although  it  does  not  attain 
the  size  of  the  organ  in  well-marked  cases  of  myelocythemia. 

Liver  and  kidneys  tend  also  to  be  enlarged ;  the  latter 
are  usually  very  pale  and  show  numerous  haemorrhages 
scattered  through  them. 

Chloroma. — This  is  a  rare  condition,  found  chiefly  in 
male  infants.  It  is  characterised  by  the  presence  of  greenish- 
coloured  tumours,  mainly  in  connection  with  the  periosteum 
of  bones,  e.g.  in  the  orbit,  causing  marked  protrusion  of  the 
eyeballs  and  on  the  vertebrae.  These,  on  microscopic  examina- 
tion, show  the  character  of  round-cell  sarcomata.  Deposits 
with  similar  characters  may  be  found  in  the  lymphatic  glands 
and  bone  marrow,  and  in  the  liver  and  kidneys.  The  colora- 
tion of  the  masses  is  due  to  a  pigment  which  occurs  in  a 
granular  form,  and  is  probably  of  a  fatty  nature. 


ILEMORRHAGIC  DISEASES  99 

Blood  films  show  appearances  similar  to  those  seen  in 
lymphocythemia. 

BJEMORRHAQIC  DISEASES 

Haemorrhages  into  the  skin,  serous  and  mucous  membranes, 
are  characteristic  of  a  number  of  conditions. 

(1)  Infective   diseases,   such   as   pyaemia   and   ulcerative 
endocarditis. 

(2)  Toxic  conditions,  such  as  jaundice,  snake  bite,  quinine 
poisoning. 

(3)  Cachectic  conditions,  as  scurvy  and  severe  anaemias.  . 
The  term  "  pur  pur  a  "  is  often  applied  when  haemorrhages 

form  a  marked  feature  of  a  case.  The  term,  however,  un- 
doubtedly includes  a  great  many  diseases  of  very  different 
nature. 

Scurvy  is  a  disease  caused  by  improper  diet — an  excess 
of  meat  (especially  salted  meat),  and  an  absence  of  fresh 
vegetables.  It  is  characterised  by  a  swollen,  spongy  con- 
dition of  the  gums  which  readily  bleed,  and  by  haemorrhages 
under  the  skin  and  into  the  muscles.  The  disease  is  believed 
to  be  an  acid  intoxication  with  diminished  alkalinity  of  the 
blood.  The  coagulation  of  the  blood  is  slow  and  incomplete, 
the  other  characters  being  those  of  a  secondary  anaemia. 
Post-mortem,  beyond  the  appearances  of  cachexia  and  the 
haemorrhages  into  the  skin  and  muscles,  there  is  little  to  note. 

Infantile  Scurvy  (Barlow's  disease)  is  a  condition 
which  is  occasionally  seen  in  infants,  not  infrequently  those 
of  the  well-to-do.  It  is  due  to  improper  dieting,  especially 
to  an  absence  of  fresh  milk  and  to  an  excess  of  proprietary 
foods.  Marked  cases  are  characterised  by  fusiform  swellings 
of  the  shafts  of  the  long  bones,  particularly  the  tibia  and 
femur.  These  swellings  are  due  to  haemorrhage  beneath 
the  periosteum.  The  periosteum  is  always  highly  vascular. 
Occasionally  the  condition  is  seen  also  in  the  upper  ex- 


ioo         DISEASES  OF  THE  BONE  MARROW 

tremities.  Fracture  of  the  shafts  of  the  long  bones  is 
occasionally  met  with.  Microscopically,  the  bones  are 
abnormally  vascular  and  there  is  absorption  of  the  bony 
trabeculse. 

Haemophilia  is  a  hereditary  disease  occurring  almost 
exclusively  in  the  males  but  transmitted  exclusively  by  the 
females  of  a  family.  It  is  characterised  by  a  tendency  to 
persistent  bleeding  either  spontaneous,  or  from  slight  wounds, 
such  as  the  socket  of  a  tooth.  Although  sometimes  fatal, 
nothing  abnormal  is  to  be  found  post-mortem.  It  is  stated 
that  there  is  an  unusual  thinness  of  the  blood-vessels  with 
fatty  change  in  the  intima.  This,  however,  is  not  always 
,  present,  and  may  be  merely  the  result  of  secondary  anaemia. 
Without  doubt  the  uncontrolled  bleedings  are  to  be  ascribed 
to  defective  coagulability  in  the  blood,  in  all  probability  to 
a  deficiency  in  the  amount  of  prothrombin.  Sometimes 
the  large  joints,  especially  the  knee,  show  in  this  condition 
appearances  not  unlike  those  found  in  rheumatoid  arthritis. 
There  is  thickening  and  fibrillation  of  the  synovial  membrane 
with  the  formation  of  fringes  which  are  coloured  yellow-red 
from  old  haemorrhages.  At  the  same  time  there  is  also 
destruction  of  the  articular  cartilages. 

DISEASES  OF  THE  BONE  MARROW 

The  bone  marrow  should  be  examined  in  such  a  readily 
accessible  position  as  the  ribs  by  compressing  the  marrow  out 
by  means  of  bone  forceps ;  also  in  the  shaft  of  one  of  the 
long  bones,  such  as  the  femur.  In  the  latter  position  the 
marrow  consists  normally  almost  entirely  of  fatty  tissue,  the 
red  marrow  of  the  long  bones  being  confined  in  the  adult  to 
the  cancellous  tissue  at  the  ends.  The  bone  (by  preference 
the  femur)  should  be  sawn  across  near  the  upper  end  of 
the  shaft.  Films  should  be  made  on  slides  or  cover-glasses 
by  smearing  the  marrow  over  the  surface.  These  can  be 


DISEASES  OF  THE  BONE  MARROW         101 

stained  directly  by  Irishman's  or  Jenner's  stain.  Portions 
of  marrow  may  also  be  fixed  (best  in  corrosive  sublimate) 
cut  in  paraffin  and  stained  by  other  means. 

The  marrow  should  be  examined  more  especially  in  all 
cases  of  anaemia,  and  in  cases  where  there  is  enlargement  of 
spleen  or  lymph  glands,  also  in  infective  conditions  such  as 
pneumonia. 

The  two  main  functions  of  the  marrow  being  the  formation 
of  red  and  white  blood  corpuscles,  two  chief  alterations  are 
found  :  (i.)  associated  with  increased  activity  in  the  white 
cell-forming  function  (Leucoblastic  marrow) ;  (ii.)  associated  with 
increased  activity  in  the  red  cell-forming  function  (erythroblastic 
marrow).  Where  either  of  those  functions  is  markedly 
stimulated,  the  fatty  marrow  of  the  long  bones  becomes 
replaced  by  leucoblastic  or  erythroblastic  marrow,  as  the 
case  may  be. 

Leucoblastic  Marrow  is  found  in  most  infective  condi- 
tions associated  with  the  presence  of  excess  of  leucocytes  in 
the  circulating  blood.  It  is  also  found  in  the  two  types  of 
leukaemia.  Leucoblastic  marrow  has  a  pink  appearance 
and  soft  consistence. 

Microscopically,  it  shows  increased  proliferative  activity 
as  evidenced  by  presence  of  mitotic  figures  in  the  nuclei  of 
the  myelocytes  (infective  conditions  and  myelocythemia)  or 
lymphocytes  (lymphocythemia),  as  the  case  may  be.  Red 
blood  corpuscles  both  nucleated  and  fully  formed  are  relatively 
diminished  in  number. 

Erythroblastic  Marrow  is  found  in  cases  where  there 
has  been  a  call  upon  the  red  cell-forming  function,  such  as 
anaemias  of  all  kinds.  The  marrow  is  redder  than  normal, 
and  the  yellow  fatty  marrow  of  the  shafts  of  the  long  bones 
is  more  or  less  altered  into  red  marrow.  In  cases  of  pernicious 
anaemia  this  alteration  is  usually  complete,  and,  in  addition, 
the  bony  trabeculae  may  be  absorbed  to  a  certain  extent, 
leaving  the  interior  of  the  shaft  fairly  smooth. 


102  DISEASES  OF  LYMPH  GLANDS 

Microscopically^  this  type  of  marrow  is  characterised  by 
marked  increase  in  the  numbers  of  the  red  blood  corpuscles, 
many  of  which  show  nuclei  in  process  of  division.  More 
especially  in  pernicious  anaemia  this  is  associated  with  the 
presence  of  large  numbers  of  large  nucleated  red  cells  or 
megaloblasts. 

Degenerations. — Fibrous  and  myxomatous  transforma- 
tion of  the  marrow  tend  to  occur  in  old  age,  syphilis,  and 
other  debilitating  diseases.  In  old-standing  cases  of  leukaemia 
and  pernicious  anaemia  degenerative  changes  may  occur. 

Pigmentary  Changes. — Another  function  of  the  marrow, 
which  it  shares  along  with  liver  and  spleen,  is  destruction  of 
effete  red  blood  corpuscles.  In  severe  anaemias  this  function 
may  be  increased,  giving  rise  in  certain  cases  to  a  brownish- 
red  coloration,  which  appears  on  microscopic  examination 
to  be  due  to  the  presence  of  blood  pigment. 


DISEASES  OF  LYMPH  GLANDS 

For  pathological  purposes  the  chief  groups  of  lymph 
glands  are :  —  cervical,  axillary,  mediastinal,  bronchial, 
mesenteric,  retroperitoneal,  pelvic,  and  inguinal. 

These  groups  should  be  examined  carefully  as  the  regions 
in  which  they  lie  are  dealt  with.  Particular  attention  should 
always  be  paid  to  the  condition  of  the  glands  in  suspected  or 
obvious  tuberculosis  or  malignant  disease. 

Pigmentary  Changes. — These  are  to  be  observed,  con- 
stantly but  in  varying  degree,  in  the  bronchial  glands,  also 
in  the  axillary  glands  in  cases  of  tattooing  of  the  skin  of  the 
arm. 

Acute  Lymphadenitis. — This  is  to  be  seen  in  the  glands 
through  which  drain  the  lymphatics  of  any  area  that  happens 
to  be  th3  seat  of  acute  inflammatory  changes ;  the  axillary  or 
inguinal  %  glands  in  cases  of  poisoned  wounds  and  bubonic 


DISEASES  OF  LYMPH  GLANDS  103 

plague ;  the  mesenteric  glands  in  typhoid  fever.  The  gland 
is  enlarged,  often  congested,  fairly  firm  in  consistence,  some- 
times with  areas  of  haemorrhage  or  necrosis,  or  even  softening 
and  suppuration. 

Microscopically ',  there  is  infiltration  with  inflammatory 
exudate,  which  is  sometimes  fibrinous ;  proliferation  and 
throwing-off  of  the  endothelial  cells  lining  the  sinuses  ;  areas 
of  haemorrhage  and  necrosis,  with  possibly  accumulations  of 
polymorphonuclear  leucocytes,  and  in  some  cases  (plague, 
typhoid),  the  causal  organism  in  considerable  numbers. 

Chronic  Lymphadenitis. — This  is  to  be  observed  in 
connection  with  areas  where  there  is  chronic  inflammation  of 
any  kind.  The  gland  is  enlarged  and  firm,  the  capsule 
thickened  and  often  adherent  to  neighbouring  glands.  On 
section,  the  structure  is  pale. 

Microscopically,  there  is  fibrous  overgrowth  in  the  capsule 
and  trabeculae.  There  is  also  catarrh  and  proliferation  of  the 
endothelial  cells  of  the  sinuses  and  proliferation  of  the 
lymphoid  cells. 

Tuberculous  Lymphadenitis. — This  is  a  very  common 
condition,  and  should  be  carefully  looked  for  in  all  cases. 
The  glands  which  are  the  seat  of  the  change  are  enlarged. 
In  the  early  stage  they  are  discrete,  and,  on  section,  grey  and 
translucent,  with,  as. a  rule,  areas  of  opaque  white  or  yellow 
caseation.  In  the  later  stages  they  tend  to  be  adherent  to 
one  another  and  to  surrounding  structures,  their  capsules  are 
thickened,  and,  on  section,  the  gland  substance  shows  caseous 
(Fig.  37)  and  sometimes  also  calcareous  change.  Evidence 
of  tuberculosis  should  be  looked  for  more  especially  in  the 
cervical,  mediastinal,  bronchial,  mesenteric,  and  retro- 
peritoneal  groups  of  glands. 

Microscopically,  in  addition  to  the  changes  found  in  a  non- 
specific chronic  inflammation  (see  above),  there  are  typical 
tubercle  follicles  and  areas  of  caseation.  Tubercle  bacilli  are 
commonly  few  and  scattered.  When  they  occur  they  are  usually 


104  DISEASES  OF  LYMPH  GLANDS 

to  be  found  in  a  zone  at  the  margin  of  the  caseous  area.  Occa- 
sionally they  may  be  found  in  considerable  numbers,  and 
sometimes  in  the  giant  and  epithelioid  cells. 

Lymphadenoma  or  Hodgkin's  Disease  (also  known  as 
Pseudoleuksemia). — This  is  a  condition  which,  on  the  one 
hand,  resembles  malignant  growths,  and,  on  the  other  hand, 
the  chronic  inflammatory  conditions,  such  as  tuberculosis. 
Certain  cases,  with  all  the  characteristic  appearances  of 
lymphadenoma,  have  been  proved  to  be  tuberculous  by 
inoculating  animals  with  portions  of  glands.  Other  cases 
resemble  very  closely  the  appearance  in  lymphosarcoma. 

The  changes  in  the  glands  consist  of  an  enlargement, 
usually  greater  than  that  found  in  tuberculosis,  of  a  group  or 
of  several  groups,  such  as  the  cervical,  axillary,  mediastinal, 
abdominal,  inguinal.  The  cervical  group  is  the  one  most 
frequently  first  affected  (Fig.  38).  The  glands  while  enlarging 
tend  to  remain  discrete  (cf.  tuberculosis).  They  vary  in 
size  from  a  pea  up  to  a  hen's  egg.  They  are  usually  firm. 
On  section,  they  are  grey  and  somewhat  translucent  with 
obvious  bands  of  shining  connective  tissue,  and  possibly  with 
yellow  areas  of  necrosis.  These  areas  of  necrosis  differ  from 
the  caseous  areas  found  in  tuberculosis  in  being  small  and 
less  opaque. 

Microscopically^  in  the  earliest  stage  there  is  a  hyperplasia 
of  the  lymphocyte  cell  elements  ;  later  there  is  a  multiplication 
of  the  endothelial  elements  at  the  expense  of  the  lymphoid 
cells,  which  may  be  relatively  few  and  far  between.  Many  of 
these  endothelial  cells  have  more  than  one  nucleus,  but  when 
there  are  several  nuclei  these  are  in  a  group,  not  peripherally 
arranged  as  in  the  typical  giant  cell  of  tuberculosis.  The 
tissue  not  infrequently  shows  infiltration  with  eosinophil  leuco- 
cytes. There  is  always  a  greater  or  less  amount  of  con- 
nective-tissue fibres,  both  in  connection  with  the  capsule  and 
in  the  substance  of  the  gland.  The  fibrous  transformation  is 
found  most  marked  in  the  more  advanced  cases.  Areas  of 
necrosis  may  be  present. 


DISEASES  OF  THE  SPLEEN  105 

Similar  changes  are  to  be  found  in  certain  of  the  internal 
organs,  more  particularly  the  spleen  (see  p.  no), less  frequently 
the  liver  (p.  191)  and  lungs. 

Tumours  of  the  Lymph  Glands.  —  Lymphomata  or 
tumours  of  lymphatic  tissue,  in  which  the  various  elements 
retain  their  normal  proportions,  may  be  found  in  the  medi- 
astinum, tonsils,  etc. 

Lymphosarcomata  or  malignant  growths  arising  in  connec- 
tion with,  and  having  the  structure  of  lymphatic  tissue,  are 
found  not  infrequently  in  the  mediastinum  invading  the 
roots  of  the  lungs,  or  in  the  abdomen.  They  tend  to  produce 
metastases  in  the  other  organs.  They  form  a  very  malignant 
type  of  tumour,  and  usually  show  microscopically  the  appear- 
ance of  a  round-cell  sarcoma. 

Secondary  growths  in  glands  are  to  be  looked  for  in  all 
cases  of  malignant  disease,  more  especially  in  carcinoma. 


DISEASES  OF  THE  SPLEEN 

Atrophy. — This  is  practically  a  normal  process  in  extreme 
old  age.  The  organ  becomes  smaller,  its  capsule  thickened 
and  shrivelled.  On  section,  there  is  found  an  increase 
of  fibrous  tissue,  the  pulp  is  of  a  dull,  reddish-brown 
colour  and  bloodless.  The  organ  is  somewhat  tough  in 
consistence. 

Waxy  or  Amyloid  Degeneration. — This  change  is  to  be 
looked  for  in  all  cases  of  prolonged  suppuration,  advanced 
tuberculosis,  and  visceral  syphilis.  There  are  two  types  of 
the  condition. 

(i)  Sago. — The  organ  is  usually  somewhat  increased  in 
size,  but  the  increase  may  not  be  marked.  In  consistence 
it  is  usually  firm,  and,  when  cut  into,  the  edges  remain  sharp. 
The  cut  surface  shows  numbers  of  round,  translucent  areas, 
uniform  in  size,  but  varying  in  size  in  different  cases,  and 


io6  DISEASES  OF  THE  SPLEEN 

regular  in  distribution   (Fig.   34).    These  give  the  typical 
mahogany  brown  reaction  with  iodine  solution. 

Microscopically ',  the  waxy  change  is  found  to  be  chiefly  in 
the  Malpighian  bodies.  The  central  artery  may  or  may  not 
be  affected.  Round  the  artery  there  is  often  an  area  com- 
paratively free  from  the  change.  The  elements  affected  are 
(i)  the  connective  tissue  of  the  capillaries,  which  run  from 
the  central  artery  to  open  into  the  pulp  ;  and  (2)  the  reticulum 
of  the  lymphoid  tissue.  The  lymphocytes  themselves  are 
pressed  upon  and  disappear.  In  addition  (3)  the  inter- 
muscular  connective  tissue  of  the  middle  coat  of  the  arterioles 
running  through  the  pulp  will  probably  show  the  change. 

(2)  Diffuse. — In  this  variety  the  organ  is  always  distinctly 
enlarged.  It  is  firm,  shows  a  sharp  margin  on  cutting,  and 
its  cut  surface  has  a  translucent  appearance  and  is  of  a  pinkish- 
red  colour.  With  iodine  a  diffuse  mahogany  brown  reaction 
is  given.  This  type  is  the  one  most  usually  found  in  syphilitic 
cases. 

Microscopically ',  the  change  may  be  found,  as  in  the  previous 
variety,  in  the  Malpighian  bodies,  but  often  it  is  restricted  to 
the  walls  (periendothelial  connective  tissue)  of  the  venous 
sinuses.  Frequently  the  sinuses  are  particularly  well  seen, 
owing  to  the  organ  being  the  seat  of  chronic  venous  congestion. 
The  arterioles  of  the  pulp,  and  sometimes  those  of  the 
Malpighian  bodies,  may  show  the  change. 

Hyaline  Degeneration  of  the  arterioles  of  the  spleen  is 
found  in  certain  infective  fevers,  such  as  diphtheria  and 
scarlatina.  The  condition  gives  rise  of  itself  to  no  obvious 
alteration. 

Microscopically ',  the  change  is  found  chiefly  in  the  intima 
of  the  arterioles,  which  show  a  homogeneous  swelling,  partially 
obliterating  the  lumen  of  the  vessels. 

Pigmentation.— The  spleen  is  specially  liable  to  post- 
mortem pigmentation  owing  to  its  position  close  to  the 
stomach  and  large  bowel.  The  organ  shows  a  greenish.- 


DISEASES  OF  THE  SPLEEN  107 

black  colour,  which  penetrates  for  a  variable  distance  into  its 
substance.  It  is  due  to  the  action  of  the  sulphuretted 
hydrogen  escaping  from  the  hollow  viscera  and  acting  upon 
the  free  iron  in  the  organ,  producing  black  sulphide  of  iron. 

In  severe  anaemias,  in  malaria,  and  in  toxic  conditions 
there  is  increase  of  iron-containing  pigment  in  the  organ. 
This,  more  particularly  in  the  case  of  anaemias,  may  be  in 
such  quantity  as  to  be  demonstrable  to  the  naked  eye.  The 
Prussian  blue  reaction  with  dilute  hydrochloric  acid  and 
potassium  ferrocyanide  is  usually  not  well  seen  in  the  case 
of  the  spleen,  owing  to  the  large  quantity  of  blood  in  the 
pulp. 

CIRCULATORY  DISTURBANCES 

Acute  Congestion  or  Active  Hyperaemia. — This  is 
constantly  seen  in  acute  toxic  conditions,  such  as  pneumonia, 
septicaemia,  acute  fevers,  etc.  The  spleen  is  enlarged,  soft 
as  a  rule  (although  in  typhoid  fever  it  is  often  fairly  firm), 
and  pale  in  colour.  On  section,  the  pulp  is  found  to  be  very 
soft,  often  capable  of  being  washed  away  in  a  stream  of 
water.  The  colour  is  a  creamy  pink.  The  Malpighian 
bodies  are  sometimes  prominent,  more  especially  in  children. 
There  are  not  infrequently  haemorrhages. 

Microscopical 'fy,  the  sinuses  are  found  to  be  distended  with 
blood,  which  shows  a  larger  proportion  of  white  cells  than 
usual.  There  is  swelling  of  the  endothelial  cells  lining  the 
sinuses,  and  these  can  often  be  seen  to  contain  red  blood 
corpuscles.  In  typhoid  fever,  areas  of  focal  necrosis  are 
always  found,  and  often  distinct  masses  of  bacilli.  In  other 
conditions,  organisms  may  be  demonstrable,  and  even  the 
commencement  of  abscess  formation  may  be  found.  True 
abscess  formation  in  the  spleen  is  rare. 

Chronic  Venous  Congestion  or  Passive  Hypersemia. — 

This  condition  is  found  in  (i)  chronic  valvular  disease  of  the 
heart,  (2)  chronic  pulmonary  disease,  (3)  cirrhosis  of  the  liver. 


io8  DISEASES  OF  THE  SPLEEN 

The  spleen  is  uniformly  enlarged,  retaining  its  normal 
shape  and  notches.  There  may  be  opaque  areas  of  chronic 
perisplenitis.  Not  infrequently  depressed  yellow  areas  (pale 
infarcts)  or  dimples  or  puckerings  indicating  absorbed  infarcts 
are  visible  on  the  surface  (Fig.  32).  The  remainder  of  the 
organ  is  of  a  dark  purple  colour.  In  consistence  it  is  firm. 
The  cut  surface  is  dark  purple,  with  white  specks  and  lines 
indicating  trabeculse,  which  may  be  more  prominent  than 
usual.  Malpighian  bodies  are  not  easily  seen. 

Microscopically,  there  may  be  some  increase  of  the  periendo- 
thelial  connective  tissue  in  the  walls  of  the  sinuses.  The 
sinuses  themselves  are  distended  with  blood.  Their  endo- 
thelial  cells  are  swollen  and  show  increased  phagocytosis  of 
red  blood  corpuscles.  Pigment  derived  from  these  latter  may 
be  seen  in  the  cells.  Under  the  microscope  it  is  exceedingly 
difficult  to  distinguish  chronic  from  acute  congestion. 

Infarction.  —  This  may  be  due  to  (i)  embolism,  (2) 
thrombosis  occurring  in  a  diseased  artery  or  vein. 

The  infarcted  areas  may  be  red  or  pale,  and  in  the  early 
stages  are  raised  above  the  surface  (Fig.  31).  Later  on  they 
become  depressed,  and  eventually  form  a  pucker  on  the 
surface  and  cicatrix  in  the  substance.  The  larger  infarcts 
may  extend  right  across  the  surface  of  the  organ.  On 
section,  the  smaller  ones  are,  as  a  rule,  wedge-shape,  and 
situated  superficially.  The  blocked  vessel  may  be  visible 
at  the  apex  of  the  wedge,  the  base  being  formed  by  the 
surface  of  the  organ.  In  the  case  of  the  older  infarcts  a 
zone  of  fibrous  tissue  forms  round  the  margin.  Within  this 
there  is  frequently  a  zone  of  yellow  (hsematoidin)  pigment. 
Rarely  the  infarcted  areas  may  undergo  softening.  This 
softening  may  be  simple  or  septic. 

Microscopic  Appearances.  —  In  the  earliest  stage  (red 
infarct)  all  that  is  to  be  noted  is  overfilling  of  the  sinuses  with 
blood  and  the  presence  of  fibrin  filaments  between  the  blood 
cells.  Later  (pale  infarct)  the  nuclei  of  the  splenic  cells  are 


DISEASES  OF  THE  SPLEEN  109 

found  to  have  lost  their  characteristic  staining  reaction.  The 
outline  of  the  sinuses  and  individual  cells  may  still  be  seen. 
Still  later,  all  evidence  of  structure  disappears.  Round  the 
infarcted  area  there  develops  a  zone  of  granulation  tissue,  con- 
sisting of  young  blood-vessels,  leucocytes,  and  fibroblasts  in 
various  stages  of  development.  Within  this  zone,  bunches  of 
yellow  acicular  crystals  of  hasmatoidin  are  frequently  to  be 
observed. 

INFLAMMATIONS 

Acute  Perisplenitis  is  seen  in  all  cases  of  acute  general 
peritonitis. 

Chronic  Perisplenitis  is  very  frequently  seen  as  pearly 
white  areas  of  thickening  in  the  capsule  of  the  organ.  The 
thickening  may  be  considerable  and  very  hard,  even  like 
cartilages.  It  is  frequent  in  cases  where  the  organ  is  enlarged, 
as  in  leukaemia.  Adhesions  to  the  parietes  are  not  in- 
frequently associated.  In  cases  of  tuberculous  peritonitis 
the  capsule  of  the  organ  often  shows  characteristic  tubercle 
granulations. 

Acute  Inflammation  of  the  Spleen  Substance  is  rare. 
In  cases  of  septic  infarction  the  commencement  of  abscess 
formation  may  be  seen. 

Chronic  Interstitial  Splenitis,  or  overgrowth  of  the 
fibrous  tissue  of  the  organ,  is  to  be  found  in  many  conditions, 
lymphadenoma,  leukaemia,  malaria. 

Tuberculosis  of  the  spleen  is  invariably  associated  with 
tubercle  elsewhere.  Two  types  of  the  condition  occur. 
(i)  The  commonest  form  is  miliary  tuberculosis  associated 
with  generalised  infection.  The  organ  is  usually  not  much 
altered  in  size.  Scattered  through  it  are  numerous  minute 
grey,  white,  or  yellow  points,  which  are  often  difficult  to 
distinguish  from  Malpighian  bodies. 

Microscopically )  there  are  found  tubercle  follicles  with  giant 
cells  and  surrounding  epithelioid  cells,  or  centres  of  commenc- 
ing caseation. 


no  DISEASES  OF  THE  SPLEEN 

(2)  The  other  form  of  tuberculosis  in  the  spleen  shows 
large,  rounded,  opaque  white  or  yellow  caseous  masses 
scattered  through  the  organ,  the  so-called  "hard -bake" 
spleen,  from  the  resemblance  to  almond  toffee  (Fig.  33). 
This  variety  is  found  chiefly  in  children. 

Lymphadenoma  or  Hodgkin's  Disease  (also  known  as 
Pseudoleuksemia).  —  This  is  a  disease  primarily  of  the 
lymphatic  glands  (p.  104).  The  spleen  is,  however,  very 
constantly  affected,  especially  in  advanced  cases.  When 
affected  the  organ  is  almost  invariably  enlarged.  The 
enlargement  is  uniform,  although  there  may  be  projections 
on  the  surface.  On  section,  numerous  opaque,  pale  bodies, 
angular  in  shape  and  more  or  less  uniformly  distributed 
(Fig.  35),  are  to  be  seen.  Sometimes  they  are  grouped  into 
masses  (Fig.  36).  At  first  grey  and  somewhat  translucent, 
they  become  more  opaque  white  in  the  later  stages,  and 
stand  out  in  marked  contrast  to  the  general  colour  of  the 
spleen  which  is  pink  to  dark  red.  The  whole  appearance 
of  the  cut  surface  is  compared  to  masses  of  suet  in  a 
pudding. 

Microscopically ',  the  appearances  are  essentially  those  seen 
in  the  lymphatic  glands.  The  change  is  primarily  in  the 
Malpighian  bodies,  which  in  the  early  stage  show  merely 
hyperplasia  of  the  lymphocyte  cell  elements.  Soon  the  large 
spindle-shaped  endothelial  cells  appear,  many  of  which  are 
multi-nucleated,  while  the  lymphocytes  diminish  in  numbers. 
The  large  endothelial  cells  tend  to  pass  into  the  pulp,  and  as 
they  are  actively  phagocytic  they  take  up  red  cells,  and  later 
show  hasmatoidin  pigment.  Fibrosis  commences  at  a  com- 
paratively early  stage,  and  later  the  Malpighian  body  may 
become  entirely  transformed  into  a  knot  of  well -developed 
fibrous  tissue.  Not  infrequently  areas  of  necrosis  occur,  as  in 
the  lymphatic  glands. 

Tumours  of  the  spleen  are  rare. 

Angiomata  and  angiosarcomata,  the  latter  with  secondary 
deposits  in  the  liver,  are  described. 


DISEASES  OF  THE  THYROID  GLAND        in 

Secondary  tumours  are  also  rare,  sarcomata  being  occasion- 
ally found. 


EXAMINATION  OF  THE  SPLEEN  REMOVED  FROM  THE  BODY 

Note  in  the  first  instance  the  size  of  the  spleen.  The 
normal  organ  measures  about  5  inches  by  3  (12.5  x  7-5  cm.), 
and  the  weight  is  5-8  oz.  (150-250  gm.).  If  the  spleen  is 
enlarged,  note  whether  this  enlargement  is  uniform,  the  organ 
retaining  its  normal  shape,  or  localised.  The  spleen  is  uni- 
formly enlarged  in  acute  congestion,  chronic  venous  congestion, 
amyloid  disease,  lymphadenoma,  leukaemia,  malaria,  etc.  It 
is  irregularly  enlarged  in  some  cases  of  lymphadenoma,  in 
tumour  and  cyst  formations.  It  is  diminished  in  size  in  the 
atrophy  of  old  age  and  in  wasting  diseases. 

Examine  the  surface  for  thickenings  of  the  capsule,  peri- 
toneal tubercles,  evidence  of  infarction,  etc.  Determine  the 
consistence.  The  normal  organ  is  moderately  firm.  In 
acute  congestion  it  is  soft,  in  chronic  venous  congestion, 
waxy  disease,  lymphadenoma,  and  leukaemia  the  consistence 
is  increased.  After  making  a  longitudinal  incision  into  the 
organ,  note  whether  the  edge  of  the  cut  becomes  rounded, 
as  is  the  case  when  the  consistence  is  soft,  or  remains  sharp, 
as  is  the  case  when  the  consistence  is  increased.  Examine 
the  cut  surface  for  the  relative  prominence  of  the  Malpighian 
bodies  (these  are  usually  much  more  obvious  in  children  than 
in  adults),  for  haemorrhages,  infarcts,  opacities,  etc.  Note 
the  general  colour  of  the  organ,  which  normally  is  brownish 
purple. 


DISEASES  OF  THE  THYROID  GLAND 

Congenital  absence  of  the  thyroid  is  found  in  cases  of 
cretinism.  Atrophy  of  the  gland  in  early  life  is  another 
cause  of  the  same  condition.  Atrophy  in  adult  life  gives  rise 
to  the  disease  myxcedema.  In  this  disease  the  gland  is 
reduced  to  a  mass  of  fibrous  tissue,  in  which  a  few  gland  acini 
may  still  be  found.  Associated  with  the  change  in  the 
thyroid  is  a  myxornatous  degeneration  of  the  subcutaneous 


H2        DISEASES  OF  THE  THYROID  GLAND 

tissue,  with  atrophy  of  the  sebaceous  glands,  hair  follicles, 
and  other  cutaneous  structures. 

Waxy  Degeneration  is  sometimes  found  well  marked 
in  the  thyroid,  the  gland  being  considerably  enlarged. 

Enlargement  of  the  Thyroid,  Goitre,  Struma,  or 
Bronchocele. 

1.  Simple  Goitre. — A  degree  of  enlargement  of  the  organ 
is  not  infrequently  found,  more  especially  and  markedly  in 
individuals    from    certain    districts,    such    as    Derbyshire. 
Whether  this  is  a  tumour  formation,  or  merely  a  dilatation 
of  the  existing  acini,  is  doubtful.     In  some  cases  there  is 
evidence  of  proliferation   of  the  gland  elements,  in  others 
none.      In    certain   cases  there  is   marked  overgrowth  of 
fibrous  tissue. 

Microscopic  Appearances. — Gland  acini  are  seen,  varying 
in  size,  some  being  greatly  dilated,  lined  with  cubical  cells, 
and  filled  with  colloid  material.  There  is  a  variable  amount 
of  supporting  connective  tissue. 

2.  Exophthalmic  Goitre. — In  the  condition  often  known 
as  Graves 's  disease  there  is  a  uniform  enlargement  of  the 
thyroid  gland  (Fig.  39).    The  gland  is  pale  pink  or  white, 
and  on  section  shows  no  evidence  of  colloid  material.     Cysts 
may  be  present,  but  their  contents  are  usually  liquid.    The 
cut  surface  is  more  like  that  of  the  pancreas  or  of  a  salivary 
gland  than  of  the  normal  thyroid. 

Microscopic  Appearances. — The  most  striking  thing  is  the 
absence,  or  almost  complete  absence,  of  colloid  material.  The 
acini  are  relatively  small  and  vary  in  shape  and  size.  The 
cells  lining  them  are  columnar  instead  of  being  cubical. 
Papillary  ingrowths  into  the  acini  may  be  seen.  Shedding  of 
the  cells  may  be  found.  There  is  marked  vascularity  of  the 
interacinous  tissue. 

Tumours. — Adenomata  and  cystic  adenomata  are  some- 
times found.  Carcinomata,  and,  more  rarely,  sarcomata 


DISEASES  OF  SUPRARENAL  GLANDS        113 

occur.    The  normal  thyroid  weighs  rather  more  than  an 
ounce  (30-40  gm.). 


DISEASES  OF  THE  THYMUS  GLAND 

This  gland  is  largest  about  the  second  year,  after  which 
it  becomes  progressively  smaller,  and  is  usually  atrophied 
after  the  twenty-fifth  year  of  life.  It  may,  however,  persist, 
and  may  be  found  enlarged  in  conditions  such  as  exophthalmic 
goitre.  It  is  also  enlarged,  along  with  the  lymph  glands  of 
the  body  generally,  in  a  condition  sometimes  found  in  children, 
where  death  may  occur  suddenly  under  the  administration 
of  chloroform,  or  without  any  obvious  reason.  This  condition 
has  been  called  status  lymphaticus  or  "  lymphatism." 

Inflammation  of  the  thymus  is  found  in  cases  of  severe 
inflammation  of  the  neck,  spreading  downwards. 

Tumours  of  the  gland  are  rare,  although  mediastinal 
sarcomata  sometimes  take  their  origin  in  it. 


DISEASES  OF  THE  SUPRARENAL  GLANDS 

It  should  be  remembered  that  the  suprarenal  gland 
represents  a  combination  of  two  types  of  tissue,  probably 
with  totally  different  functions.  The  cortical  portion  is 
formed  of  columns  of  gland  cells  with  intervening  capillary 
vessels.  The  cells  are  polygonal,  and,  in  the  fresh  condition, 
contain  large  quantities  of  myelin  and  other  fatty  bodies ; 
hence  the  yellow  colour  of  the  cortex.  The  function  of  the 
cortical  portion  has  not  yet  been  satisfactorily  decided. 

The  medullary  portion  of  the  gland  is  grey  to  the  naked 
eye,  with  red  spots  scattered  through  it,  indicating  vessels. 
Microscopically,  it  is  found  to  consist  of  blood  spaces  lined 
with  endothelium,  and  between  these  ganglion  cells  with  a 
peculiar  affinity  for  neutral  salts  of  chromic  acid.  These 
chromaffin  or  chromophil  cells,  which  are  also  found  in  the 

8 


ii4        DISEASES  OF  SUPRARENAL  GLANDS 

pituitary  gland,  the  carotid  body,  and  the  coccygeal  glands, 
are  believed  to  be  the  cells  which  secrete  adrenin.  In  all 
cases  where  the  suprarenal  is  suspected  to  be  at  fault  the 
gland,  as  well  as  other  parts  containing  chromaffin  cells,  should 
be  fixed  in  a  chrome  salt  fixative,  such  as  Miiller's  fluid,  and 
cut  in  gum  (see  p.  354). 

Accessory  Suprarenals. — These  may  be  found  not  only  in 
the  kidney,  liver,  and  tissue  in  the  immediate  neighbourhood 
of  the  suprarenal,  but  also  in  the  broad  ligament  and  ovary. 
They  are  known  as  suprarenal  or  adrenal  rests,  and  it  is 
believed  that  they  form  the  starting-point  of  certain  tumours 
known  as  hypernephromata.  These  "  rests "  are  formed 
usually  only  of  the  cortical  portion  of  the  gland. 

Haemorrhages  into  the  suprarenal  are  not  very  infrequent. 
They  occur,  more  especially  in  children,  in  fevers  and  in 
wasting  conditions.  Such  haemorrhages  may  be  the  cause 
of  sudden  death. 

Tuberculosis. — This  shows  itself  in  two  forms. 

1.  As  a  part  of  a  general  tuberculosis  with  small  caseous 
nodules  in  the  gland,  as  in  other  organs  and  tissues. 

2.  As  a  fibro-caseous  process  involving  both  glands,  often 
the   only  tuberculous   manifestation   in   the  body,  causing 
complete  destruction  of  the  organ.    This  is  the  type  of 
change  commonly  associated  with  Addison's  disease. 

Addison's  Disease. — Besides  the  above-mentioned  chronic 
tuberculosis  of  the  suprarenals,  there  have  been  found  in 
cases  of  Addison's  disease  fibroid  atrophy  of  the  suprarenal 
and  tumour  formation.  In  a  few  cases  the  glands  have 
been  found  normal,  but  the  semilunar  ganglia  and  chrom- 
affin tissue  generally  have  been  affected. 

Tumours. — Hypernephromata   or   tumours,   the    cells    of 
which  resemble  those  of  the  cortex  of   the  normal  gland 
may  grow  from  the  suprarenal.      They  may  be  simple  or 
malignant  (p.  224). 


DISEASES  OF  SUPRARENAL  GLANDS        115 

Carcinomata  and  sarcomata  may  also  be  found.  They 
are  usually  secondary,  and  commonly  there  are  deposits  in 
both  organs.  The  weight  of  the  suprarenals  varies  consider- 
ably. It  has  been  given  as  4-7  grammes.  The  left  is  slightly 
the  heavier. 


CHAPTER   VII 

DISEASES   OF  THE  RESPIRATORY   SYSTEM 

DISEASES  OF  THE  LARYNX 

(Edema,  also  called  oedema  glottidis. — This  may  be  due 
to  the  swallowing  of  boiling  water,  to  acute  inflammation 
in  the  neighbourhood,  e.g.  acute  tonsillitis.  It  may  also  occur 
in  association  with  kidney  and  heart  disease.  The  parts 
most  affected  are  the  posterior  surface  of  the  epiglottis,  the 
aryteno-epiglottic  folds,  and  the  false  cords.  The  condition 
is  serious,  from  its  interference  with  respiration.  It  shows 
itself  by  swelling  of  the  parts  affected,  which  are  pale  and 
have  a  translucent  appearance. 

Laryngitis. — Acute  and  chronic  catarrhal  conditions  of 
the  larynx  show  little  that  is  obvious  after  death.  There  may 
be  hypersemia  and  collection  of  mucus. 

Membranous  Laryngitis.  —  This  is  most  commonly 
diphtheritic  in  origin,  although  it  may  be  due  to  streptococcal 
infection.  It  may  occur  in  the  course  of  other  specific 
fevers,  such  as  typhoid  and  smallpox.  It  occasionally  is 
caused  by  the  presence  of  foreign  bodies,  such  as  fish  bones. 
The  membrane  usually  occurs  also  over  the  tonsils  and 
pharynx,  and  may  spread  downwards  into  trachea  and 
bronchi.  The  membrane  is  commonly  firmly  adherent  in 

116 


DISEASES  OF  THE  BRONCHI  117 

the  pharyngeal  region.  In  trachea  and  bronchi  it  is  easily 
removable  (Fig.  44).  The  membrane  has  a  white  or  grey 
appearance,  and  the  subjacent  tissue  and  surrounding  parts 
are  acutely  congested. 

Tuberculosis  of  the  Larynx. — This  condition  is  usually 
secondary  to  pulmonary  tuberculosis.  It  is  characterised 
by  the  deposit  of  tuberculous  granulations,  with  subsequent 
ulceration.  The  ulcers  are  found  over  the  epiglottis,  aryteno- 
epiglottic  and  inter-arytenoid  folds.  At  first  superficial, 
they  tend  to  extend  deeply,  eroding  the  vocal  cords,  and 
even  the  cartilage  in  the  neighbourhood.  The  margins  of 
the  ulcers  are  raised  and  nodular. 

Syphilis  of  the  Larynx. — This  may  occur  both  in 
hereditary  and  in  acquired  syphilis,  and  both  as  a  secondary 
and  tertiary  manifestation.  In  the  secondary  stage  catarrhal 
inflammation  and  mucous  patches  occur,  in  the  tertiary 
stage  gummata,  ulceration,  and  subsequent  cicatrisation  and 
stenosis.  Ulceration,  when  it  occurs,  tends  to  destroy  cartilage 
as  well  as  soft  parts,  such  as  the  base  of  the  tongue  and 
pharynx. 

Tumours  of  the  Larynx.  —  Among  simple  tumours, 
papillomata  and  fibromata  occur.  Of  malignant  growths, 
carcinomata  are  more  common  than  sarcomata. 


DISEASES  OF  THE  BRONCHI 

Acute  Bronchitis. — Inflammation  of  the  bronchi  may 
be  caused  by  many  different  organisms,  e.g.  staphylo cocci, 
streptococci)  pneumococcus ,  micrococcus  catarrhalis.  In 
addition,  irritating  fumes,  such  as  those  of  ammonia,  may 
produce  it.  Inflammatory  conditions  of  the  smaller  bronchi 
are  often  accompanied  by  inflammation  in  the  contiguous 
portions  of  lung  (broncho-pneumonia). 

The  appearances  in  acute  bronchitis  are  swelling  and 


n8   DISEASES  OF  THE  RESPIRATORY  SYSTEM 

congestion  of  the  mucous  membrane,  with  the  presence  of 
a  fibrinous  or  purulent  exudate.  When  the  bronchi  within 
the  lung  substance  are  affected,  squeezing  of  the  lung 
expresses  beads  of  purulent  material. 

Microscopic  Appearances. — The  most  striking  change  is 
desquamation  of  the  ciliated  epithelial  cells,  which  are  found 
lying  free  in  the  exudate  along  with  polymorphonuclear 
leucocytes.  The  basement  membrane  upon  which  the  epithelial 
cells  rest  is  swollen.  The  underlying  vessels  are  congested, 
and  the  surrounding  tissue  infiltrated  with  inflammatory  cells. 
The  cells  of  the  mucous  glands  are  swollen  and  granular. 

Chronic  Bronchitis. — This  condition  may  be  organismal, 
following  the  acute  form,  or  it  may  be  associated  with  the 
occupation,  the  individual  working  in  an  atmosphere  in 
which  there  are  many  foreign  particles,  e.g.  carbon,  stone, 
steel,  etc.  In  appearance  there  may  be  little  alteration 
from  the  normal.  Sometimes  the  lumen  of  the  tubes  is 
dilated.  The  mucous  membrane  may  be  pale  or  congested. 
Occasionally  there  may  be  superficial  ulceration.  There  is 
always  a  considerable  amount  of  frothy  muco-purulent 
secretion  in  the  tubes,  which  may  show  more  or  less  pigmenta- 
tion from  the  presence  of  foreign  particles.  The  condition 
is  usually  accompanied  by  emphysema  of  the  lungs,  and 
often  by  dilatation  of  the  right  side  of  the  heart. 

Microscopically,  the  epithelium,  when  present,  is  of  a 
cubical  rather  than  of  a  columnar  type.  In  places  the 
epithelium  may  be  entirely  absent.  The  basement  membrane 
is  often  thickened  and  the  subjacent  tissue  infiltrated  with 
inflammatory  cells  of  a  small,  round,  lymphocyte-like  type. 
There  is  usually  overgrowth  of  fibrous  tissue,  and  structures 
such  as  bronchial  muscle  and  mucous  glands  may  be  atrophied. 
The  lumen  of  the  tubes  contains  desquamated  epithelial  cells 
and  polymorphonuclear  leucocytes,  mixed  with  strings  of 
fibrinous  material. 

Tuberculous  Bronchitis. — Tuberculous  lesions  of  the 
larger  bronchi  are  not  commonly  met  with,  although  tubercles 


DISEASES  OF  THE  LUNGS  119 

may  develop  in  the  mucous  membrane  and  subsequently 
ulcerate.  Lesions  of  the  smaller  bronchi  within  the  lung  are 
common  in  pulmonary  tuberculosis.  Peribronchial  tubercles 
may  break  through  into  the  lumen  of  the  tubes  and  lead  to 
ulceration.  The  smaller  bronchi  not  infrequently  dilate 
through  weakening  of  their  walls  by  inflammatory  change. 
Such  dilatations  may  form  the  starting-point  of  cavities. 

Syphilitic  Bronchitis. — Gumma  formation,  with  sub- 
sequent ulceration,  although  uncommon,  is  met  in  the 
larger  bronchi,  usually  at  their  commencement,  and  in  the 
trachea  at  its  bifurcation. 

A  number  of  cases  of  sudden  death  from  haemorrhage 
through  erosion  of  a  large  vessel  (pulmonary  artery,  left 
bronchial  artery,  superior  vena  cava)  by  such  an  ulcer  have 
been  recorded. 

Bronchiectasis,  or  dilatation  of  the  bronchi,  is  usually 
met  with  in  connection  with  an  interstitial  pneumonia 
(tuberculosis,  syphilis).  The  dilatation  may  be  fusiform  or 
saccular.  It  is  produced  by  traction  on  the  part  of  the 
contracting  fibrous  tissue  in  the  neighbourhood  together  with 
adherence  of  the  lung  to  the  chest  wall.  A  generalised 
dilatation  of  the  bronchi  may  follow  collapse  of  a  lung. 

Bronchiolectasis,  or  dilatation  of  the  bronchioles,  is  a 
common  occurrence  in  broncho-pneumonia,  more  especially 
in  children.  The  walls  of  the  tubes,  weakened  by  the  in- 
flammatory process  and  under  pressure  from  within  through 
coughing,  distend.  As  a  rule  the  amount  of  distention  is 
small,  but  in  certain  cases  it  may  go  on  to  such  a  degree  that 
large  cavities  are  produced  in  which  secretion  accumulates. 
Such  a  condition  has  been  called  "  honeycomb  lung." 

DISEASES  OF  THE  LUNGS 

Collapse. — A  lung  which  is  not  consolidated,  and  which 
is  not  held  in  position  by  adhesions  between  the  two  layers 


120    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

of  the  pleura,  the  moment  that  the  pleural  cavity  is  opened 
collapses  to  about  one-third  of  its  bulk.  Such  lungs  are 
therefore  always  observed  in  this  semi-collapsed  condition. 
A  similar  condition,  or  one  which  is  more  complete,  may  be 
produced  during  life  by  the  presence  of  air  in  the  pleural 
cavity,  or  from  dropsical  or  purulent  fluid  in  the  sac.  In 
such  a  case  the  lung  is  of  a  slate-grey  colour  (Fig.  41), 
anaemic,  tough,  and  sinks  in  water.  On  squeezing,  few  or  no 
air-bubbles  can  be  expressed  from  the  cut  surface.  If  the 
collapsed  condition  have  persisted  for  long,  there  will  be 
overgrowth  of  fibrous  tissue,  and  sometimes  dilatation  of 
the  bronchi.  If  adhesions  bind  portions  of  the  lung  to  the 
parietal  pleura,  the  collapse  will  be  partial. 

Collapse  of  small  portions  of  lung  is  often  observed  post- 
mortem, more  particularly  in  the  lower  and  posterior  parts 
of  the  organ.  These  appear  as  dark  purple  areas  slightly 
depressed  below  the  general  surface.  They  can  be  reinflated 
by  pressing  air  into  them  from  neighbouring  parts. 

Similar  small  areas  of  collapse  are  found  in  cases  of  broncho- 
pneumonia.  They  are  due  to  blocking  of  the  smaller  bronchi 
with  exudate,  and  the  subsequent  absorption  of  the  air  by 
the  blood. 

Localised  collapse  may  also  be  found  in  the  lung  in  the 
neighbourhood  of  aneurysms  or  tumours  pressing  directly 
upon  the  lung. 

Microscopic  Appearances. — The  alveolar  walls  are  relaxed 
and  approximated.  The  vessels  are  usually  dilated.  There 
may  be  evidence  of  catarrh  in  the  alveoli.  Increase  of  fibrous 
tissue  may  be  observed.  The  elastic  tissue  appears  to  be 
increased,  but  that  is  merely  because  of  the  relaxation  of  the 
lung  substance  and  the  condensation  of  the  fibres. 

Atelectasis. — This  is  a  condition  similar  to  the  above, 
which  may  be  found  in  the  new-born  child,  but  as  it  is  due 
to  want  of  expansion,  the  term  "  collapse,"  although  some- 
times used,  is  scarcely  applicable.  The  condition  may  be 


DISEASES  OF  THE  LUNGS  121 

complete  or  partial.  When  partial,  it  is  commonest  in  the 
lower  lobe,  especially  in  its  posterior  part.  The  organ  which 
is  the  seat  of  the  change,  instead  of  being  pale  pink  and 
crepitant,  is  dark  red,  tough,  and  airless.  If  the  condition 
is  partial,  the  area  affected  is  depressed  below  the  air-contain- 
ing portion.  The  affected  portion  sinks  in  water  (see  p.  310). 

Emphysema. — Two  varieties  of  this  condition  are  found 
in  the  lung :  (i)  vesicular  emphysema,  or  over-distention 
of  the  air  vesicles  of  the  lung ;  (2)  interstitial  emphysema, 
or  the  escape  of  air  into  the  fibrous  supporting  tissue  of 
the  lung. 

(i)  Vesicular  Emphysema. — This  is  a  condition  of  over- 
distention  of  the  lung  alveoli  caused  by  (a)  forcible  distention 
of  the  air  vesicles  from  constant  coughing,  as  in  chronic 
bronchitis,  or  from  the  blowing  of  wind  instruments;  (b) 
the  giving  way  of  the  elastic  network  of  alveolar  walls 
before  a  normal  pressure ;  this  may  be  due  to  wasting  disease, 
to  old  age,  or  to  an  inherent  imperfect  development  of  the 
tissue.  The  portions  of  the  lung  most  affected  are  the  apex, 
the  anterior  and  lower  borders,  that  is  to  say,  those  portions 
where  over-distention  can  occur  most  readily.  The  lung  is 
pale  (Fig.  40),  light,  and  has  a  spongy  feel,  like  the  sensation 
given  on  pressing  a  bag  of  feathers.  On  section,  it  is  dry 
and  bloodless.  There  may  be  areas  of  very  marked  dis- 
tention forming  small  bladders  or  bullae.  The  condition 
is  usually  associated  with  chronic  bronchitis  and  enlargement 
of  the  right  side  of  the  heart.  Hypertrophic  and  atrophic 
forms  of  emphysema  are  distinguished;  in  the  former  the 
organ  is  more  voluminous,  in  the  latter  it  is  smaller  than 
usual.  The  hyper  trophic  type  is  found  in  cases  where 
forcible  distention  from  coughing  is  the  cause,  the  atrophic 
type  in  cases  of  wasting  disease  in  old  age,  or  where  the 
elastic  tissue  of  the  organ  is  naturally  imperfectly  developed. 

Complementary  or  compensatory  emphysema  is  found  in 


122    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

small  areas  of  lung  in  close  approximation  to  areas  of  collapse 
or  to  areas  of  shrinkage  from  fibrosis.  This  latter  type, 
found  in  the  neighbourhood  of  healed  tubercle  foci,  may  be 
called  traction  emphysema  (p.  146). 

Microscopic  Appearances. — There  is  marked  over-distention 
of  the  air  vesicles  and  smaller  air  passages.  The  smaller 
vessels  have,  to  a  great  extent,  disappeared.  The  elastic  fibres 
of  the  alveolar  walls  are  stretched  and  widely  separated. 
The  bronchi  may  show  evidence  of  chronic  catarrh. 

(2)  Interstitial  emphysema  is  a  rare  condition  when,  owing 
to  rupture  of  the  lung  from  injury  (e.g.  fractured  rib,  stab, 
or  bullet  wound)  or  disease  (e.g.  gangrene,  emphysema),  the 
air  escapes  into  the  fibrous  supporting  tissue.  In  this 
position  it  works  its  way  to  the  root  of  the  lung,  and  eventually 
into  the  mediastinum  and  areolar  tissue  of  the  neck, 

CIRCULATORY  CHANGES 

Acute  Congestion  or  Hyperaemia.  —  This  condition  is 
usually  found  preceding  or  associated  with  inflammation 
of  the  lung.  It  will  be  described  in  connection  with 
pneumonia. 

Passive  Congestion  or  Hypersemia. — Two  varieties  of 
this  condition  may  be  distinguished. 

1.  Hypostatic   congestion,   a   condition   frequently   found 
post-mortem,  more  especially  in  cases  where  the  circulation 
has  been  slowly  failing.    As  the  name  indicates,  it  is  in  the 
posterior  parts  of  the  lung  (the  parts  where  gravity  has  most 
influence  on  the  blood)  that  the  condition  is  most  marked. 
The  area  involved  is  dark  purple  in  colour,  and  is  often  the 
seat  of  oedema  and  inflammatory  consolidation. 

2.  Chronic  Venous  Congestion  of  the  Lung. — This  occurs 
where  there  is  long-standing  obstruction  to  the  passage  of 
the  blood  through  the  lungs,  as  in  cases  of  chronic  valvular 
disease  of  the  left  side  of  the  heart.    The  organ  is  of  a  dark 


DISEASES  OF  THE  LUNGS  123 

red,  sometimes  brick -red  colour,  and  in  the  later  stages 
it  is  of  firmer  consistence,  hence  the  term  "  brown 
induration.'7  Not  infrequently  infarcts  are  present  in  such 
lungs. 

Microscopic  Appearances. — The  vessels  generally  are  dilated, 
and,  in  the  case  of  the  alveolar  capillaries,  they  project  into  the 
interior  of  the  air  vesicles  and  are  obviously  thickened.  Red 
blood  cells  may  be  found  free  in  the  spaces,  also  shed  endothelial 
(catarrhal  cells)  containing  pigment  derived  from  broken-down 
red  corpuscles.  Catarrhal  changes  will  also  probably  be  found 
in  the  bronchi,  and  there  may  be  some  increase  of  fibrous 
tissue,  but  this  is  seldom  in  sufficient  amount  as  to  be  obvious 
under  the  microscope.  In  the  hypostatic  variety  oedema  and 
more  acute  inflammatory  changes  may  be  present. 

Haemorrhage  into  the  lung  substance  may  occur  in  the 
form  of  minute  petechial  hemorrhages,  usually  under  the 
pleura.  Such  are  found  in  severe  anaemias,  in  cases  of  death 
from  suffocation,  and  in  infective  conditions.  Larger  haemor- 
rhages are  found  in  infarction,  in  severe  inflammations, 
and  in  gangrene ;  also  sometimes  in  tuberculosis. 

Infarction  (Pulmonary  Apoplexy). — This  is  a  common 
condition  to  find  in  lungs  the  seat  of  chronic  venous 
congestion.  When  the  area  of  lung  involved  is  large,  the 
condition  may  be  the  cause  of  sudden  death.  The  causation 
of  the  condition  is  not  quite  clear,  as  it  is  difficult  to  produce 
infarction  experimentally  by  the  injection  of  artificial  emboli. 
In  a  majority  of  cases,  however,  the  artery  leading  to  the 
area  will  be  found  plugged  with  an  embolus,  and  on  careful 
examination  a  source  will  be  found  for  the  embolus,  e.g.  a 
thrombus  in  the  right  auricular  appendix  or  in  a  vein  (see 
diagram,  p.  62).  Another  view  of  the  causation  is  that  it  is 
due  to  thrombosis  in  the  vessel,  not  to  embolism.  Another 
that  it  is  merely  due  to  escape  of  blood  from  a  burst 
capillary  into  the  spongy  tissue  of  the  lung. 

The  condition  is  more  frequently  found  in  the  lower  lobes 


124   DISEASES  OF  THE  RESPIRATORY  SYSTEM 

than  in  the  upper.  It  occurs  specially  at  the  margins  of  the 
lung  (anterior  and  lower)  and  towards  the  surface,  not  in 
the  substance. 

The  area  involved  is  more  or  less  angular  (Fig.  45).  It  is 
raised  above  the  general  surface  of  the  organ  ;  that  is  to  say^ 
it  remains  distended  when  the  neighbouring  lung  undergoes 
partial  collapse.  It  is  usually  dark  purple  in  colour  and 
hard  in  consistence.  Occasionally  it  may  be  pale  from  sub- 
sequent decolorisation.  Sometimes  a  zone  of  fibrous  tissue 
develops  around  the  infarct,  and  the  area  may  undergo 
softening  or  it  may  cicatrise.  Infarcts  of  the  lung,  however, 
seldom  show  the  later  changes  found  in  infarcts  elsewhere. 
This  is  no  doubt  partly  due  to  the  fact  of  the  double  blood 
supply  of  the  lung.  It  is  also  due  to  the  fact  that  many  of 
the  infarcts  occur  shortly  before  death,  and  in  some  instances 
are  the  actual  cause  of  death. 

Microscopic  Appearances. — In  the  area  involved,  the  alveoli 
are  filled  with  red  blood  cells  and  fibrin,  or,  in  other  words, 
with  blood  clot.  There  are  also  leucocytes  present,  more 
especially  at  the  margin.  The  cells  of  the  alveolar  walls  show 
some  loss  of  staining  reaction,  but  necrotic  changes  are  not 
frequently  found  in  infarcts  of  the  lung.  There  may  also  be  a 
development  of  fibrous  tissue  round  the  area. 

(Edema. — This  is  an  exceedingly  common  condition.  It 
is  found  in  cases  in  which  dropsy  tends  to  occur  elsewhere, 
as  in  heart  disease  and  in  Bright's  disease.  It  is  also  very 
commonly  present  in  cases  where  death  has  occurred  slowly,  as 
in  wasting  diseases,  e.g.  cancer,  anaemia.  It  is  frequently  com- 
bined with  hypostatic  congestion,  and  tends  to  occur  in 
the  more  dependent  portions  of  the  lung.  Thus  it  is  more 
frequent  in  the  posterior  portions  of  the  lower  lobe.  Occasion- 
ally, however,  it  is  most  marked  in  the  upper  lobe.  (Edema 
frequently  occurs  in  the  neighbourhood  of  pneumonic  areas. 
The  organ  is  pale  unless  congestion  is  superadded.  It  is 
bulky  and  feels  fairly  solid,  but,  unlike  a  pneumonic 


DISEASES  OF  THE  LUNGS  125 

lung,  it  pits  on  pressure.     When  one  cuts  into  it  and  presses 
the  lung  substance,  frothy  fluid  escapes. 

Microscopically,  the  alveoli  are  found  distended,  their 
contents  being  finely  granular  material,  which  is  all  that  is  left 
of  the  albuminous  exudate  after  the  tissue  has  been  fixed, 
hardened,  and  cut.  Catarrhal  cells  and  leucocytes  are  also 
usually  present  within  the  alveoli. 


INFLAMMATIONS  OF  THE  LUNG— PNEUMONIA 

Types  of  Pneumonia. 

1.  Acute  lobar  pneumonia  (croupous  pneumonia). 

2.  Lobular  pneumonia  (catarrhal  pneumonia). 

3.  Purulent  (septic)  broncho-pneumonia. 

4.  Hypostatic  pneumonia. 

5.  Interstitial  pneumonia. 

1.  Acute  Lobar  Pneumonia 

This  condition,  also  called  Croupous  Pneumonia,  is  so  well 
defined  that  it  may  be  called  a  specific  disease.  It  is  due  in 
the  vast  majority  of  cases  to  the  diplo coccus  pneumonia.  This 
organism  is  accompanied  not  infrequently  by  B.  pneumonia, 
streptococci)  staphylococci,  B.  influenza,  B.  typhosus.  Occasion- 
ally these  organisms  are  present  by  themselves. 

The  condition,  as  its  name  indicates,  is  one  which  usually 
involves  the  whole  or  the  greater  part  of  the  lobe  of  a  lung.  The 
right  lung  is  more  frequently  the  seat  of  the  disease  than  the 
left,  and  the  lower  lobe  than  the  upper  lobe.  Not  infre- 
quently the  whole  of  one  lobe  and  a  portion  of  another  lobe 
may  be  affected,  and  less  frequently  both  lungs  may  show 
the  change.  Orth  gives  the  percentage  of  involvement  of 
the  two  lungs  as  follows  : — right,  52  ;  left,  33 ;  both  lungs,  15. 

The  term  croupous  is  applied  because  of  the  type  of  exudate 
present  in  the  lung  alveoli,  which  is  essentially  fibrinous. 


126    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

For  reasons  of  convenience  it  is  customary  to  divide  the 
process  into  four  stages  :  (i)  stage  of  active  hypercemia  or 
acute  congestion,  (2)  stage  of  red  hepatisation,  (3)  stage  of 
grey  hepatisation,  (4)  stage  of  resolution.  The  distinction 
between  these  stages  is  an  entirely  artificial  one.  Frequently 
more  than  one  of  them  are  to  be  observed  in  one  and  the  same 
lung.  By  themselves  the  first  two  are  rarely  seen/ owing 
to  the  fact  that  death  does  not  often  occur  during  the  early 
stages  of  the  disease.  They  are,  however,  not  infrequently 
seen  in  areas  of  the  lung  in  which  the  later  stages  are  present 
in  neighbouring  parts. 

(1)  Stage  of  Acute  Congestion. — As  regards  the  naked-eye 
appearances  at  this  stage  there  is  little  more  to  be  observed 
than  a  bright  red  colour  in  the  lung  substance  on  section. 
The  lung  substance  is  still  crepitant  and  spongy. 

Microscopic  Appearances. — The  vessels  of  the  lung  gener- 
ally, and  the  capillaries  in  the  wall  of  the  alveoli  in  particular, 
are  distended  with  blood.  This  condition  of  the  capillaries 
gives  a  beaded  appearance  to  the  walls  of  the  air  vesicles. 
Within  the  lumen  of  the  vesicles  may  be  found  a  few  red  blood 
corpuscles,  a  few  catarrhal  cells  thrown  off  from  the  wall,  and 
a  minute  quantity  of  exudate.  Suitably  stained  specimens 
may  show  germs. 

(2)  Stage  of  Red  Hepatisation.    Naked-eye  Appearances. — 
The  lung  is  distended  and  contrasts  markedly  with  the  semi- 
collapsed  condition  of  the  ordinary  lung.    Not  infrequently 
the  markings  of  the  ribs  may  be  seen.    There  is  usually  some 
slight  amount  of  fibrinous  exudate  over  the  area  of  lung 
involved.     In  consistence  the  organ  isfirm^  like  a  solid  organ 
such  as  the  liver.    It  cuts  readily,  quite  unlike  the  soft, 
yielding,   unconsolidated   lung.     The   organ   is   immensely 
increased  in  weight.    A  small  portion  removed  and  placed 
in  water  at  once  sinks. 

The  cut  surface  of  that  portion  of  the  lung  which  shows 
the  change  has  a  reddish  colour,  which,  on  account  of  its 


DISEASES  OF  THE  LUNGS  127 

being  mottled  with  paler  areas  and  accumulations  of  black 
pigment,  has  been  compared  with  red  granite.  Usually 
the  cut  surface,  more  especially  the  paler  areas,  has  a  granular 
appearance,  owing  to  the  projection  of  plugs  from  the  alveoli. 
On  squeezing  the  lung  substance,  only  a  little  blood  and 
serous  fluid,  but  no  air,  can  be  expressed.  Those  portions 
of  lung  not  'actually  consolidated  may  show  congestion,  and 
sometimes  cedema. 

On  opening  up  the  bronchi  their  mucous  membrane  is 
found  swollen  and  injected  and  their  lumen  filled  with  sticky 
rust-tinged  exudate.  The  bronchial  glands  are  swollen  and 
pink  in  colour. 

Microscopic  Appearances.  —  Instead  of  the  fenestrated 
appearance  of  the  normal  lung  section,  the  lung  which  is  the 
seat  of  this  change  appears  like  a  solid  organ.  The  alveoli 
are  filled  with  plugs  consisting  of  a  network  of  fibrin  threads, 
sometimes  communicating  with  the  coagulum  in  a  neighbour- 
ing vesicle  through  one  of  the  stomata.  In  the  meshes  of  the 
fibrin  are  catarrhal  cells,  a  few  red  blood  corpuscles,  and  con- 
siderable numbers  of  leucocytes,  chiefly  of  the  polymorpho- 
nuclear  type.  In  suitably  stained  specimens  organisms  can 
usually  be  found. 

In  the  walls  of  the  alveoli  the  vessels  are  still  distended 
with  blood.  The  bronchi  show  evidence  of  acute  inflamma- 
tion. The  interlobular  septa  and  the  supporting  fibrous  tissue 
of  the  lung  generally  are  swollen  and  infiltrated  with  fibrin  and 
leucocytes.  The  pleura  shows  the  changes  of  acute  inflamma- 
tion. Films  made  from  the  bronchial  exudate  will  show 
leucocytes,  fibrin,  desquamated  epithelium,  both  flattened  and 
columnar,  and  characteristic  germs.  This  last  is  the  best 
source  from  which  to  demonstrate  the  pneumococcus. 

(3)  Stage  of  Grey  Hepatisation.  Naked-eye  Appearance. — 
The  organ  is  distended  as  before,  shows  rib  markings  and 
fibrinous  exudate  on  the  pleura  over  the  affected  lobe.  As 
before,  it  is  firm,  heavy,  and  a  portion  removed  sinks  in  water. 
The  cut  surface,  however,  is  pale,  and,  with  the  black  mottling 
of  the  carbon,  is  not  unlike  grey  granite  in  appearance  (Fig.  42). 


128    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

The  granularity  of  the  cut  surface  is  more  marked,  and,  on 
scraping  the  surface  with  a  knife,  turbid  fluid  and  plugs  from 
the  alveoli  can  be  removed.  On  squeezing,  similar  fluid  can 
be  expressed,  but  no  air-bubbles.  On  opening  up  the  bronchi 
the  mucous  membrane,  as  before,  is  found  to  be  swollen  and 
injected ;  the  contents  have  a  more  opaque  white  appearance. 

Microscopic  Appearances. — The  alveoli  and  smaller  air 
passages  are  filled,  as  before,  with  plugs,  which  are,  however, 
at  this  stage  retracted  from  the  walls,  this  space  having  been 
filled  during  life  with  fluid.  The  fibrin  threads  are  not  so 
obvious  ;  they  are  broken  down  and  granular.  In  the  meshes 
of  the  coagulum  are  vastly  more  numerous  cells,  the  increase 
being  entirely  due  to  the  accumulation  of  polymorphonuclear 
leucocytes.  Many  of  these  stain  badly  owing  to  degenerative 
changes.  Germs  are  often  difficult  to  find  at  this  stage.  The 
capillaries  in  the  walls  of  the  alveoli  are,  to  a  large  extent, 
obliterated  by  the  pressure  of  the  contents  of  the  air  vesicles. 
Bronchi,  interlobular  septa,  and  pleura  show,  as  in  the  earlier 
stage,  evidence  of  inflammation. 

(4)  Stage  of  Resolution.  Naked-eye  Appearances. — The 
lung  is  still  somewhat  distended,  but  is  now  much  softer. 
From  the  cut  surface  considerable  quantities  of  grey,  milky 
fluid  can  be  expressed. 

Microscopic  Appearances. — The  alveolar  plug  is  contracted 
still  more,  and  may  be  absent  altogether.  The  contents  of 
the  alveoli  are  granular  material  and  degenerated  leucocytes. 
Multiplication  in  the  endothelial  cells  of  the  alveoli  is  often 
seen,  as  evidenced  by  their  greatly  increased  number.  These 
may  be  found  surrounding  the  remains  of  the  plug.  The 
capillaries  of  the  alveolar  walls  are  again  distended  with 
blood. 

Other  terminations  than  resolution  in  the  case  of  lobar 
pneumonia  are  :  (i)  septic  softening,  which  may  go  on  to 
gangrene  ;  (2)  fibrosis,  or  overgrowth  of  the  fibrous  support- 
ing tissue  of  the  lung,  producing  chronic  interstitial  pneumonia. 

In  carrying  out  a  post-mortem  in  a  case  of  acute  lobar 


DISEASES  OF  THE  LUNGS  129 

pneumonia,  the  following  conditions,  more  especially,  should 
be  looked  for  in  organs  other  than  the  lung  : — 

(1)  A  leucoblastic  condition  of  the  bone  marrow  associated 
with   the   marked   polymorphonuclear   leucocytosis   of   the 
blood  in  the  disease. 

(2)  Acute  congestion  of  the  spleen. 

(3)  Cloudy  swelling  of  liver,  kidneys,  and  heart  muscle. 
Other  conditions  which  may  complicate  the  disease  are 

ulcerative  endocarditis,  pericarditis,  meningitis,  peritonitis. 

2.  Lobular  Pneumonia 

Synonymous  terms  for  this  condition  are :  (i)  broncho- 
pneumonia,  from  the  fact  that  areas  of  lung  in  connection 
with,  and  around  bronchi  are  involved;  (2)  catanhal 
pneumonia,  from  the  character  of  the  exudate  most 
characteristically  found  in  the  alveoli. 

The  etiology  of  the  condition  may  be  said  to  be  the  same 
as  in  the  lobar  form  of  pneumonia.  It  is  more  frequent 
in  children,  and  is  the  form  of  inflammation  of  the  lung  found 
in  the  specific  fevers.  The  matter  might  be  put  in  this  way ; 
that  pneumocpccic  infection  of  the  lung  in  children  usually 
shows  the  lobular  type.  When  the  lobular  type  occurs  in 
adults,  the  causal  germ  is  usually  some  other  organism  than 
the  pneumococcus ,  e.g.  streptococci,  staphylo cocci. 

Naked-eye  Appearances. — The  lung  may  be  slightly  more 
distended  than  normal.  It  has  a  mottled,  red  surface, 
with  (i)  dark  purple  depressed  areas  of  collapse,  (2)  red,  firm 
areas  of  consolidation,  and  (3)  pale  areas  of  compensatory 
emphysema.  On  handling  it,  irregularly  scattered  areas  of 
a  firmer  consistence  than  the  rest  can  be  felt.  On  section, 
the  same  mottled  appearance  is  visible,  with  dark  purple 
areas  of  collapse  where  a  bronchus  has  become  plugged,  pink 
areas  of  consolidation,  more  or  less  rounded  (Fig.  43),  in  the 
centre  of  which  can  often  be  seen  a  small  bronchus,  from 

9 


130    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

which,  on  squeezing  the  lung,  a  small  bead  of  thick  white 
secretion  can  be  pressed,  also  paler  emphysematous  areas. 
The  lung  tissue  generally  is  congested.  On  opening  up  the 
bronchi,  their  mucous  membrane  is  found  swollen  and  con- 
gested, with  more  or  less  purulent-looking  secretion.  The 
bronchial  glands  are  congested  and  swollen.  The  smaller 
bronchi  and  bronchioles  within  the  lung  substance  are  not 
infrequently  dilated,  sometimes  to  such  an  extent  that  a 
"  honeycomb  "  appearance  is  produced  (see  Bronchiolectasis). 

Microscopic  Appearances. — To  realise  the  true  nature  of  the 
change,  large  sections  of  lung  should  be  cut.  The  consolida- 
tion will  then  be  seen  to  be  patchy  in  its  distribution,  the 
plugged  alveoli  being  usually  situated  round  a  small  bronchus 
or  bronchiole  as  their  centre.  This  bronchus  shows  the 
appearance  of  acute  bronchitis,  and  its  wall  is  infiltrated 
with  inflammatory  cells.  The  elastic  coat  may  be  ruptured, 
and  not  infrequently  the  lumen  is  dilated.  The  alveoli  around 
contain  plugs  which  may  be  more  fibrinous  or  more  leucocytic, 
the  appearances  varying  considerably  in  different  types  of  the 
disease  and  in  different  positions.  Towards  the  margin  of  the 
area  more  of  the  cells  filling  the  alveoli  are  of  the  catarrhal 
type,  i.e.  they  are  cast  off,  swollen  endothelial  cells.  Hence 
the  term  "catarrhal  pneumonia."  The  walls  of  the  alveoli 
generally  show  congestion  of  their  vessels. 

Broncho-pneumonia  may  resolve  or  may  pass  into  septic 
pneumonia  or  gangrene. 

The  associated  changes  in  spleen,  bone  marrow,  etc.,  are 
the  same  as  in  lobar  pneumonia. 

3.  Purulent  or  Septic  Broncho-Pneumonia 

This  condition  may  occur  : — 

(1)  As  a  sequel  to  broncho-pneumonia,  especially  when  of 
the  so-called  aspiration  type,  e.g.  associated  with  the  inhala- 
tion of  septic  material,  as  after  operations  on  the  mouth. 

(2)  Associated  with  obstruction  to  the  bronchi,  as  by  tumour 


DISEASES  OF  THE  LUNGS  131 

or  aneurysm    leading    to  retention  of    secretion  •  (so-called 
"  retention  "  pneumonia). 

(3)  Associated  with  the  presence  of  a  foreign  body  in  the 
bronchi. 

(4)  As  a  blood  infection  due  to  the  deposition  of  organisms 
or  infective  thrombi  in  the  pulmonary  vessels  (embolic  or 
metastatic  pneumonia))  found   specially  in  such  conditions 
as  osteomyelitis  and  pyaemia.    Septic  infarcts  are  not  in- 
frequently associated.     Such  infarcts  have  the  same  distribu- 
tion and  often  very  much   the  same   appearance   as   the 
non-septic  type  (see  p.  123),  but  they  tend  to  be  paler  and 
often  show  softening  in  their  centre.    Under  the  microscope 
such   infarcts   are   characterised   by   immense   numbers   of 
polymorphonuclear  leucocytes  in  addition  to  red  blood  cells, 
also  by  masses  of  organisms. 

The  appearances  are  the  same  as  in  broncho-pneumonia, 
but  the  inflammatory  changes  are  more  acute,  and  there  is 
a  greater  tendency  to  destruction  of  pulmonary  tissue.  The 
bronchi  are  filled  with  purulent  material. 

Abscess. — This  condition  is  usually  associated  with 
embolic  pneumonia  or  septic  infarction.  The  abscesses  are 
commonly  small,  but  they  may  extend  and  pass  on  to  gangrene. 
They  are  surrounded  with  a  zone  of  consolidated  lung. 

Gangrene. — This  is  usually  a  secondary  condition,  the 
result  of  putrefactive  organisms  reaching  a  consolidated  or 
necrosed  portion  of  lung.  Thus  it  may  follow  lobar  or  septic 
pneumonia,  infarction  or  abscess.  It  may  also  be  due  to 
direct  extension,  as  from  a  ruptured  ulcer  of  the  oesophagus, 
or  from  a  subphrenic  abscess.  It  may  be  due  to  the  presence 
of  foreign  bodies  in  the  bronchi,  such  as  coins  or  false  teeth. 

The  area  involved  is  at  first  intensely  congested,  later  it 
becomes  black,  and  the  lung  substance  breaks  down  and 
comes  away,  leaving  a  cavity  (Fig.  46)  lined  with  black  or 
greenish-black  walls,  the  colour  being  due  to  changes  in  the 


132    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

effused  blood.  The  contents  of  these  cavities  and  of  the 
bronchi  are  usually  brown,  like  prune  juice,  but  may  be  paler, 
like  pus  or  putty.  The  neighbouring  portions  of  lung  show 
pneumonic  consolidation.  The  odour  is  always  most  offensive. 

4.  Hypostatic  Pneumonia 

This  is  a  type  of  pneumonia  associated  with  hypostatic 
congestion  and  O3dema  of  the  lungs,  and  therefore  found  in  the 
posterior  and  lower  portions.  It  is  the  type  of  inflammation 
which  supervenes  in  old  age,  and  in  wasting  diseases  generally. 

The  distribution  of  the  change  allows  of  immediate 
recognition.  The  consolidation  is  usually  partial  and 
associated  with  oedema. 

Microscopically ',  the  appearances  differ  in  different  parts — 
congestion,  oedema,  with  catarrhal,  fibrinous,  and  leucocytic 
consolidation,  all  being  found  in  close  contact. 

5.  Interstitial  Pneumonias 

These  are  conditions  in  which  there  is  increase  in  the 
fibrous  tissue  of  the  lung.  They  may  be  divided  into  three 
groups : — 

(1)  Those  following  previous  acute  pneumonia. 

(2)  Those  due  to  the  inhalation  of  dust  of  various  kinds. 

(3)  Those  due  to  chronically  acting  bacterial  poisons,  tuber- 
culosis, syphilis,  actinomycosis. 

Interstitial  Pneumonia  following  acute  lobar  or  lobular 
pneumonia  is  a  comparatively  rare  condition.  It  usually 
shows  itself  as  localised  areas  of  thickening  of  pleura  and 
interlobular  septa  also  of  the  fibrous  tissue  at  the  root  of  the 
organ.  Sometimes  it  is  more  diffuse,  involving  considerable 
areas  of  lung  tissue.  In  this  condition,  as  in  other  types 
where  there  is  marked  thickening  of  the  alveolar  walls, 
the  endothelial  cells  of  the  alveoli  may  become  cubical. 

Interstitial    Pneumonia  due  to   the   Inhalation    of   Dust 


DISEASES  OF  THE  LUNGS  133 

(Pneumokoniosis). — There   are   three   common   varieties   of 
this,  according  to  the  type  of  dust  inhaled : — 

(1)  Anthracosis  or  coalminer's  lung. 

(2)  Silicosis  or  stonemason's  lung,  also  known  as  Chalicosis. 

(3)  Siderosis  or  needle-grinder's  lung. 

In  all  these  conditions  the  foreign  particles  which  are 
inhaled  are  absorbed  into  the  lymphatics,  partly  by  the 
action  of  phagocytes.  They  tend  to  be  deposited  along  the 
course  of  the  lymphatics,  and  there  to  set  up  irritation  and 
consequent  fibrosis.  Thus  nodules  of  fibrous  tissue  develop 
beneath  the  pleura,  along  the  interlobular  septa,  bronchi, 
and  vessels.  The  lymph  glands  at  the  root  of  the  lung  are 
enlarged  and  indurated.  Owing  to  the  irritant  action  of  the 
foreign  particles  preparing  the  way  for  germs,  tuberculosis 
is  a  very  common  accompaniment  of  all  these  conditions. 
They  are  also  frequently  complicated  by  chronic  bronchitis 
and  emphysema,  and  by  a  degree  of  catarrhal  pneumonia, 
and  occasionally  by  bronchiectasis.  The  siliceous  particles 
are  more  irritating  than  the  carbon,  hence  the  nodules  of 
fibrous  tissue  tend  to  be  larger  in  silicosis  than  in  anthracosis  ; 
there  are  also  more  catarrhal  changes  in  the  alveoli.  The 
steel  particles  are  more  irritating  than  the  siliceous,  hence 
the  changes  are  most  marked  of  all  in  siderosis. 

Anthracosis. — There  is  always  a  certain  amount  of 
pigmentation  in  the  lung  of  town  dwellers,  and  also  in  most 
country  dwellers.  This  is  enormously  accentuated  in  those 
who  work  in  coal  mines.  When  well  marked  the  condition 
is  known  as  anthracosis.  The  lung  is  usually  black,  or  almost 
black,  with  small,  hard,  black  nodules  scattered  under  the 
pleura  and  in  the  lung  substance  (Fig.  48).  On  squeezing, 
there  exudes  an  inky-black  fluid.  The  bronchial  glands  are 
enlarged,  deeply  pigmented,  and  indurated. 

Microscopic  Appearances.  —  The  nodules  are  found  to 
consist  of  well -formed  fibrous  tissue  mixed  with  carbon 


134    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

pigment.  They  occur  under  the  pleura,  along  the  interlobular 
septa,  bronchi,  and  vessels.  The  superficial  layer  of  the  pleura 
is,  however,  free  from  pigment.  There  is  some  degree  of 
catarrhal  change  in  bronchi  and  alveoli,  and  some  thickening 
of  the  vessels. 

Silicosis. — The  lungs  in  this  condition  are  grey  in  appear- 
ance, and,  scattered  through  them,  are  numerous  grey  nodules, 
which  are  hard  and  gritty  to  the  touch.  Similar  nodules  are 
present  in  large  numbers  under  the  visceral  pleura.  They 
tend  to  be  larger  than  those  in  anthracosis  (Fig.  47). 

The  disease  is  not  unlike  the  more  chronic  forms  of  tuber- 
culosis, and,  as  already  pointed  out,  it  is  not  infrequently 
complicated  by  it.  The  pure  condition  may  be  distinguished 
from  tuberculosis  by  the  hard  and  gritty  character  of  the 
nodules  and  by  the  absence  of  cavitation. 

Microscopic  Appearances.  —  These  are  the  same  as  in 
anthracosis  but  the  pigment  is  not  so  obvious  (although  carbon 
pigment  is  also  present),  and  there  is  more  catarrhal  change  in 
the  surrounding  lung.  There  may  be  endarteritis  obliterans 
of  the  vessels.  Tuberculosis  is  often  superadded. 

Siderosis. — The  nodules  in  this  type  are  larger,  owing 
to  the  greater  irritation  of  the  metal  particles.  The  lungs 
have  a  grey  appearance  and  may  be  almost  solid.  Evidence 
of  tuberculous  disease  is  very  frequently  present  in  addition. 

Microscopically,  in  addition  to  the  larger  areas  of  fibrosis, 
there  is  more  catarrhal  change  in  the  alveoli,  between  the 
nodules  of  fibrous  tissue. 

Syphilitic  Disease :  (a)  White  Pneumonia. — This  is  a 
condition  occasionally  found  in  children  suffering  from 
congenital  syphilis.  The  lungs  are  pale  and  firmer  than 
normal. 

Microscopically,  there  is  found  an  overgrowth  of  fibrous 
tissue  involving  the  walls  of  the  individual  alveoli.  The 
endothelium  lining  the  alveoli  is  cubical  instead  of  being- 
flattened. 


DISEASES  OF  THE  LUNGS  135 

(b)  Gummata. — These  occur  as  small  caseous  foci  surrounded 
by   fibrous   tissue.    They   are   not   infrequently   absorbed, 
leaving  puckered  cicatrices  behind.    They  are  indistinguish- 
able from  tuberculous  caseous  masses. 

(c)  Interstitial  Pneumonia  in  acquired  syphilis  occurs  as 
areas  under  the  pleura  or  towards  the  root  of  the  lung.    There 
is  thickening  of  the  pleura,  of  the  interlobular  septa,  and 
increase  of  fibrous  tissue  around  the  bronchi  and  vessels. 
The  last  usually  show  endarteritis  obliterans. 

Microscopically,  there  is  overgrowth  of  fibrous  tissue, 
usually  catarrh  of  the  alveoli,  and  often  accumulations  of  small 
round,  cells  (miliary  gummata). 

TUBERCULOSIS 

Tuberculosis. — The  lungs  are  by  far  the  commonest 
site  for  tuberculous  disease.  In  a  large  proportion  of  cases 
the  disease  does  not  progress  far  and  soon  heals,  leaving 
merely  some  cicatricial  tissue  behind.  The  apex  of  the  lung 
is  the  seat  of  election  for  the  disease.  Very  often  the 
apices  of  both  the  upper  and  lower  lobes  are  affected. 
The  disease  may  reach  the  lung  by  any  of  four  paths  :  (i) 
the  air  passages,  (2)  the  blood-vessels,  (3)  the  lymphatic 
vessels,  or  (4)  by  direct  extension.  In  most  cases  it  is  im- 
possible to  say  by  what  avenue  the  disease  originally  came. 
Nevertheless,  certain  statements  can  be  made  regarding 
this  question  of  the  path  of  entrance,  (i)  Where  the  tubercle 
lesions  are  uniformly  scattered  through  the  organ,  the  disease 
has  been  brought  by  the  blood-stream,  and  search  should  be 
made  for  some  older  focus  of  infection  in  some  other  part  of 
the  body  or  in  the  lung  itself.  This  focus  is  commonly  a 
lymph  gland  which  has  become  adherent  to,  and  eventually 
has  ruptured  into,  a  vein  or  a  large  lymphatic  trunk,  such  as 
the  thoracic  duct.  Not  infrequently  the  source  is  a  focus 
in  the  lung  itself  which  has  invaded  a  branch  of  the  pulmonary 


136    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

vein.  The  condition  is  always  associated  with  disseminated 
metastatic  tuberculosis  in  other  organs,  although  the  areas 
may  not  be  visible  to  the  naked  eye. 

(2)  Where  the  lesions  are  arranged  in  groups,  in  a  cluster 
like  a  bunch  of  grapes  (staphyloid  arrangement),  the  condition 
has  probably  been  spread  by  the  lymphatics,  and  a  vessel  or 
bronchus  will  be  found  in  the  centre  of  the  group.    This 
arrangement  is  sometimes  found  distributed  throughout  the 
lung.      More   often,  however,  this   appearance   is   seen   in 
areas  of  the  lung  where  there  is  an  older  lesion  at  some  point, 
and  it  is  always  seen  at  the  margin  of  a  spreading  lesion  of 
the  more  chronic  type. 

(3)  Where  there  is  a  localised  lesion  (and  commonly,  as 
we  have  seen,  it  is  at  the  apex  of  the  upper  lobe  or  at  the 
apex  of  both  upper  and  lower  lobe)  the  general  view  is 
that  the  infective  agent  has  been  inhaled.    The  reason  for 
the  apical  position  is  probably  because  that  portion  of  the  lung 
receives  relatively  less  blood.    Moreover,  it  is  the  portion 
of  lung  which  moves  least  during  respiration.    There  is  great 
diversity  of   opinion  upon  this  question.    Another  view  is 
that  the  infection  has  spread  from  the  lymphatics  of  the 
neck  to  the  apex  of  the  pleural  cavity.    There  it  sets  up  a 
localised  pleurisy  with  the  formation  of  adhesions,  along  which 
the  bacillus  passes  to  the  apex  of  the  lung.    Again,  the  spread 
may  be  less  direct,  the  infection  passing  from  the  cervical 
glands  to  the  mediastinal  and  bronchial,  and  so  outward  into 
the  lymphatics  of  the  lung  itself.     In  these  cases  of  infection 
by  way  of  the  cervical  lymph  channels  the  tonsil  is,  in  all 
probability,  the  portal  through  which  the  germs  enter.    A 
third  view  is  that  the  infection  is  by  way  of  the  blood-stream, 
and  that,  owing  to  the  greater  susceptibility  of  the  apex, 
the  disease  has  progressed  at  that  point  and  not  at  others. 

(4)  Very  occasionally  the  disease  may  spread   directly 
from  a  diseased  rib  or  vertebra,  or  through  the  diaphragm 
from  the  abdominal  cavity. 


DISEASES  OF  THE  LUNGS  137 

Mode  of  Spread. — Once  started,  the  tuberculous  lesion 
tends  to  spread  in  four  ways  : — 

(1)  By  direct  continuity,  passing  from  alveolus  to  alveolus, 
and  from  one  part  of  the  lung  to  another. 

(2)  By  the  Air  Passages. — A  focus  invades  a  bronchus,  and 
sets  up  a  tuberculous  inflammation.    The  secretion  is  inhaled 
into  the  areas  of  lung  to  which  that  bronchus  passes.    Or 
infected  secretion  is  coughed  up  for  some  distance  and,  in 
the  deep  inspiration  following  a  fit  of  coughing,  it  is  inhaled 
into  the  bronchi  in  other  portions  of  the  lung,  even  into  the 
bronchi  of  the  opposite  lung. 

(3)  By  the  Lymphatics. — Tuberculosis  is  essentially  a  disease 
which  spreads  by  lymphatics.    This  lymphatic  spread  shows 
itself  in  the  occurrence  of  areas  of  fibro-caseous  change  in 
the  lymph  channels  around  a  focus  of  the  disease,  having 
the  staphyloid  arrangement  already  mentioned.    It  is  also 
shown  by  implication  of  the  nearest  lymphatic  glands. 

(4)  By  the  Blood—  Chronic  tuberculosis  leads  to  thickening 
of  the  vessels.    Acute  tuberculosis  tends  to  invasion  of  the 
vessel  wall  and  the  infection  of  the  blood.    The  vessels  of  the 
lung  are  relatively  thin  walled.    Invasion  of  a  branch  of  the 
pulmonary  artery  will  lead  to  further  infection  of  the  area 
of  lung  supplied  by  that  artery.     Invasion  of  a  branch  of  a 
pulmonary  vein  will  lead  to  systemic  infection  in  which  the 
lungs  will  participate.    This  is,  however,  not  such  a  common 
occurrence  as  might  be  expected,  owing  to  the  fact  that  the 
tuberculous    process    is    accompanied    by    non-specific    in- 
flammatory changes,  which  tend  to  obliterate  a  vessel  before 
invasion  with  tuberculous  material  can  occur. 

According  to  one  authority  this  is  the  way  in  which  the 
lung  is  infected  in  most  cases.  Infection  of  the  bronchial 
glands  occurs  first,  one  of  the  affected  glands  becomes 
adherent  to  a  large  branch  of  the  pulmonary  artery,  and 
infective  material  in  this  way  enters  the  pulmonary  circula- 
tion. 


138    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

Characters  of  the  Lesions. — The  tuberculous  lesions  tend 
to  occur  in  the  form  of  isolated  foci.  These  may  be  widely 
separated  from  one  another,  or  so  closely  packed  that  they 
are  practically  continuous.  They  are  either  grey  and  more 
or  less  translucent  when  they  are  formed  of  cellular  elements 
and  fibrous  tissue,  or  opaque  white  or  yellow  when  these 
elements  have  undergone  caseation.  There  is  always  a 
certain  amount  of  interstitial  change  or  fibrous  tissue  forma- 
tion, both  in  the  lesions  and  in  the  lung  around. 

In  the  more  acute  cases  this  fibrous  tissue  formation  is 
minimal.  In  such  cases  the  condition  tends  to  spread 
diffusely,  involving  more  or  less  of  lung  substance  and 
producing  a  catarrhal  consolidation  of  the  alveoli  which  sub- 
sequently undergoes  a  caseous  change  (caseous  pneumonia). 

Microscopically,  the  tuberculous  lesion  is  characterised  by 
a  cell  aggregation,  the  individual  cell  elements  showing  three 
types  :  ( i )  large  multinucleated  or  giant  cells,  the  nuclei  of 
which  are  arranged  commonly  in  a  circle,  or  part  of  a  circle, 
round  a  central  clear,  necrotic  area  ;  (2)  spindle-shaped  and 
branched  cells,  with  nuclei  resembling  those  of  the  giant  cell, 
and,  arranged  round  that  cell  (epithelioid  or  endothelioid  cells)  ; 
(3)  lymphocyte-like  cells,  with  small  dark-staining  nuclei  and 
little  protoplasm. 

Polymorphonuclear  leucocytes  are,  except  in  very  acute  cases, 
relatively  few  in  number.  The  giant  cell  is  not  infrequently 
absent,  and  its  place  occupied  by  an  area  where  the  cells  are 
breaking  down.  This  area,  as  it  enlarges,  loses  all  appearance 
of  structure.  It  is  the  commencement  of  the  caseous  process. 
In  addition,  there  is  always  more  or  less  overgrowth  of  fibrous 
tissue.  In  the  more  acute  cases  caseation  predominates, 
in  the  more  chronic,  fibrous  tissue  formation.  Where  this 
inflammatory  process  invades  the  alveoli  there  is  consolidation 
of  the  lung,  a  consolidation  characterised  by  the  presence  of 
some  exudate,  not  as  a  rule  fibrinous,  with  numerous  catarrhal 
cells  and  leucocytes.  This  consolidated  area  of  lung  also  tends 
to  undergo  the  caseous  alteration  whereby  it  becomes  ap- 
parently structureless,  but  in  this  caseous  focus  the  fibrous 


DISEASES  OF  THE  LUNGS  139 

tissues,  and  more  especially  the  elastic  fibres,  persist  for  long 
almost  unchanged. 

The  elastic  fibres  of  the  lung  undergo  some  destruction  both 
by  fragmentation  and  solution,  in  the  area  where  cells  and 
nuclei  are  breaking  down.  The  fibres  which  escape  this 
primary  destruction  may  persist  in  the  caseous  area  for  an 
almost  indefinite  period.  It  is  largely  for  this  reason  that 
necrotic  caseous  areas  of  lung  remain  firm.  When  secondary 
infection  with  pyogenic  and  other  forms  of  microbes  occurs, 
complete  destruction  of  the  elastic  fibres  and  softening  of  the 
caseous  area  takes  place,  the  softened  material  is  coughed  up, 
and  a  cavity  results.  Another  way  in  which  cavity  formation 
not  infrequently  starts  is  by  inflammation  of  the  walls  of  a 
bronchus  or  bronchiole.  The  wall,  weakened  by  the  inflam- 
matory process,  next  gives  way  under  the  increased  pressure 
associated  with  coughing.  Destructive  changes  then  occur, 
and  a  cavity  results  which  subsequently  extends. 

Classification  of  Tuberculous  Affections  of  the  Lungs. — 
The  most  satisfactory  classification  would  probably  be 
upon  the  basis  of  the  path  of  infection,  but,  owing  to  the 
fact  that  in  most  instances  it  is  practically  impossible  to  be 
certain  of  the  path  of  entrance  of  the  disease,  owing,  further, 
to  the  fact  that  even  in  a  case  of  probable  air-passage  infec- 
tion the  disease  may  spread  by  the  lymphatics,  and  even  by 
the  blood-vessels,  this  method  is  not  entirely  satisfactory. 
Another  method  of  classification  is  on  the  basis  of  the  main 
underlying  histological  change.  As  we  have  seen,  there  are 
essentially  two  such  changes  in  pulmonary  tuberculosis  : 
(i)  a  filling  up  of  the  alveoli  with  exudate  and  cells  (mainly 
catarrhal) ;  in  other  words,  pneumonia  or  inflammatory 
consolidation.  The  consolidated  area  subsequently  under- 
goes a  necrotic  (caseous)  change.  This  type  of  lesion  is 
characteristic  of  the  more  acute  conditions,  i.e.  where  the 
virulence  of  the  organism  is  high  or  the  resistance  of  the  in- 
dividual low.  (2)  A  laying  down  of  new  fibrous  tissue  usually 
in  relation  to  pre-existing  fibrous  tissue  (interalveolar,  inter- 
lobular,  etc.),  i.e.  fibrosis,  or  interstitial  pneumonia.  This 


140   DISEASES  OF  THE  RESPIRATORY  SYSTEM 

occurs  in  cases  where  the  organism  possesses  a  relatively  low 
degree  of  virulence  or  where  the  soil  (i.e.  the  individual)  is 
unusually  resistant.  The  two  changes  are  commonly  found 
side  by  side,  but  sometimes  the  one  predominates,  sometimes 
the  other. 

Probably  no  method  of  classification  is  completely  satis- 
factory, but  the  following  has  for  long  been  found  useful  by 
the  author.  It  has  the  advantage  of  describing  in  general 
terms  the  appearance  of  the  lung  condition  as  a  whole.  It 
may  be  regarded  as  a  compromise  between  the  two  methods 
mentioned  above. 

1.  Miliary  or  Disseminated  Metastatic   Tuberculosis  (as 
suggested  by  Orth). 

2.  Caseous    or    Tuberculous    Broncho-Pneumonia,    or,    if 
diffuse,  Caseous  or  Tuberculous  Pneumonia.    This  condition 
may  or  may  not  be  accompanied  by  cavity  formation.    This 
includes  the  conditions  which  are  usually  described  as  acute 
phthisis. 

3.  Fibro-caseous  Tuberculosis,  again  either  with  or  without 
cavitation.    This  includes  the  condition  known  as  chronic 
phthisis. 

There  are  objections  to  the  above  method  of  classification, 
but  on  the  whole  it  will  be  found  that  most  types  of  pulmonary 
tuberculosis  can  in  this  way  be  satisfactorily  described. 

The  method  avoids  the  use  of  the  term  "  phthisis,"  which 
is  really  a  clinical  one,  and  not  infrequently  incorrect  at  that, 
meaning,  as  it  does,  a  wasting  disease.  The  terms  used 
merely  form  a  starting-ground  from  which  to  detail  the  more 
minute  changes. 


1.  Miliary  Tuberculosis  or  Disseminated  Metastatic 
Tuberculosis 

This  condition  is  usually  blood-spread,  but  may  be  spread 
by  the  lymphatics.    It  is  associated  with  an  older  tuberculous 


DISEASES  OF  THE  LUNGS  141 

focus  in  the  lung,  bronchial  glands,  or  a  lesion  in  some 
other  part  of  the  body.  This  primary  focus  should  be  sought 
for.  Where  the  condition  is  blood-spread,  tubercles  will  be 
found  scattered  through  other  organs  and  tissues ;  if  not 
large  enough  to  be  seen  by  the  naked  eye,  they  will  be 
found  on  microscopic  examination. 

Naked-eye  Appearance. — The  lung  is  uniformly  congested. 
Scattered  through  its  substance  are  immense  numbers  of 
grey,  white,  or  yellow  foci  (Fig.  49),  which  may  vary  in  size 
from  something  just  visible  to  an  area  one  or  two  millimetres 
in  diameter.  Frequently  the  areas  vary  in  size  in  different 
parts  of  the  lung.  Sometimes  they  are  found  to  be  larger 
in  the  upper  portions  of  the  lung.  Sometimes  the  areas  are 
arranged  in  groups  (staphyloid  arrangement)  round  blood- 
vessels or  bronchi,  indicating  that  the  spread  has  been  by 
way  of  the  lymphatics.  Where  the  distribution  is  uniform 
throughout,  spread  by  the  blood-stream  is  most  probable. 

Microscopic  Appearances.  —  Scattered  through  the  lung 
substance  between  individual  alveoli,  around  bronchi  and 
blood-vessels  and  interlobular  septa,  are  rounded  areas  of  cell 
accumulation.  The  cells  composing  these  are  chiefly  mono- 
nuclear,  of  the  epithelioid  and  lymphocyte  type  with  catarrhal 
cells  and  a  few  polymorphs.  Sometimes  in  the  centre  there  are 
giant  cells  ;  at  other  times  the  centre  is  occupied  by  an  area 
where  the  cells  and  their  nuclei  are  breaking  down.  Not  in- 
frequently there  is  a  distinct  structureless  caseous  centre.  In 
specimens  stained  for  elastic  fibres  there  will  be  found  some 
destruction  of  these  in  the  central  area  if  they  have  been  included. 
In  other  cases  (the  more  chronic  type)  the  fibres  are  merely 
pushed  aside  by  the  aggregating  cells. 

There  is  always  a  certain  amount  of  involvement  of  the 
surrounding  lung  alveoli.  Those  alveoli  in  the  immediate 
neighbourhood  are  consolidated  with  exudate,  catarrhal  cells, 
and  leucocytes.  As  this  area  of  alveolar  involvement  enlarges, 
the  condition  tends  to  pass  into  the  second  type — caseous 
broncho  -  pneumonia.  There  is  usually  more  or  less  new 
formation  of  fibrous  tissue  in  and  around  the  nodules.  In  the 


142    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

more  acute  type  with  necrotic  centre  this  is  minimal.  In 
suitably  stained  specimens  tubercle  bacilli,  although  few  in 
number,  will  be  found,  more  particularly  in  the  acute  type. 
Not  infrequently  bronchi  and  vessels  will  be  seen  in  course 
of  invasion  by  the  nodules.  It  is  this  secondary  invasion  of 
vessels  which  largely  accounts  for  the  great  number  of  the 
tubercles,  and  for  their  variation  in  size,  due  to  the  fact  that 
they  are  of  different  ages. 

2.  Gaseous  or  Tuberculous  Broncho-Pneumonia 
or  Caseous  Pneumonia 

Two  types  of  this  condition  can  be  distinguished  : — 

(1)  A   type   in   which   there   are   areas   of  consolidation 
scattered  through  the  lung,  spread  by  the  blood  or  by  the 
lymphatics.    This  type  is  merely  an  example  of  the  previous 
condition  where  there  has  been  fairly  extensive  spread  into 
the  surrounding  lung,  so  that  a  considerable  group  of  alveoli 
have  become  consolidated  and  have  then  undergone  the 
caseous  change  (Fig.  50).    This  type  is  found  practically  ex- 
clusively in  children.    The  individual  areas  may  fuse  with  one 
another,  so  that  the  consolidation  may  be  complete,  involving 
a  whole  lobe.     Occasionally  cavity  formation  may  be  found. 

(2)  A  type  which  commences  in  one  particular  portion  of 
the  lung,  usually  near  the  apex  of  the  upper  lobe,  and  spreads 
from  that  point.     In  such  a  case  the  infection  is  generally 

believed  to  have  been  by  way  of  the  air  passages.  This  type 
is  the  common  one  found  in  progressive  acute  tuberculosis 
in  the  adult.  It  is  only  occasionally  seen  in  the  early  stages, 
owing  to  the  fact  that  it  does  not  prove  fatal  until  well 
advanced.  Sometimes,  however,  the  initial  stages  are  met 
with  in  cases  dying  of  diabetes  or  other  wasting  disease. 
Usually,  as  the  condition  is  met  with  in  the  post-mortem 
room,  the  area  of  consolidation  is  extensive  and  cavitation 
present  (Fig.  51).  Sometimes  a  less  advanced  type  of  the 
disease  is  found  in  one  lung  when  in  the  other  a  more 
advanced  stage  exists. 


DISEASES  OF  THE  LUNGS  143 

Naked-eye  Appearances. — The  lung  shows  chronic,  occasion- 
ally acute,  pleurisy  on  the  surface.  It  is  partially  consolidated, 
usually  the  area  of  consolidation  being  towards  the  apex. 
The  cut  surface  shows  areas  of  a  white  or  slightly  yellow,  opaque 
appearance,  not  unlike  grey  hepatisation.  These  may  be 
isolated  and  scattered,  but  there  is  usually  one  considerable 
area  which  may  involve  the  greater  part  of  a  lobe.  In  these 
areas  are  cavities,  usually  small  and  often  numerous,  with 
ragged  walls.  In  advance  of  these  areas,  and  often  widely 
scattered  through  the  lung,  are  grey  or  yellow  tubercles  in 
groups,  indicating  lymphatic  spread  (Fig.  51).  Besides  spread 
by  the  lymphatics,  spread  by  the  bronchi  (aspiration)  and  by 
direct  continuity  of  tissue  is  observed  in  this  condition.  The 
bronchi  show  evidence  of  acute  bronchitis  and  the  lymph 
glands  at  the  root  of  the  lung  are  enlarged  and  show  grey 
tubercles  and  caseous  foci.  There  is  usually  more  or  less 
fibrosis  in  connection  with  this  type.  As  the  fibrosis  pre- 
dominates, it  passes  into  the  next  type. 

This  type  of  the  disease  has  to  be  differentiated  from  acute 
lobar  and  lobular  pneumonia  and  gangrene  of  the  lung,  also 
from  growths  of  the  lung.  The  main  points  to  remember 
in  making  this  distinction  are  :  i.  Position — tuberculous 
lesions  commonly  apical.  2.  Extent — tuberculous  lesions 
as  a  rule  involving  only  a  portion  of  a  lobe.  3.  Surrounding 
parts — the  presence  in  the  case  of  tuberculosis  of  foci  of 
lymph-spread  disease  in  the  neighbouring  portions  of  lung. 
4.  Cavities — characteristic  of  tuberculosis,  present  also  in 
gangrene,  but  in  the  latter  the  cavities  possessing  soft  friable 
black-coloured  margins  and  the  other  appearances  character- 
istic of  tuberculosis  (e.g.  lymphatic-spread  nodules)  being 
absent. 

Microscopic  Appearances. — The  two  essential  processes 
going  on  are  :  (i)  a  catarrhal  consolidation  of  the  lung  alveoli 
which  undergoes  a  caseous  change  ;  (2)  lymphatic  spread  of 
the  disease,  with  formation  of  caseating  tubercles  along  the  lines 


144   DISEASES  OF  THE  RESPIRATORY  SYSTEM 

of  the  lymphatics.  These  tend  to  spread  into  surrounding 
alveoli  and  bronchi,  and  so  to  initiate  fresh  areas  of  caseous 
pneumonia.  The  elastic  tissue  of  the  lung  undergoes  a  certain 
amount  of  destruction,  but  in  the  caseous  areas  the  network  is 
preserved  and  tends  to  persist  until  cavitation  occurs.  There 
is  usually  a  certain  amount  of  increase  of  fibrous  tissue  as 
evidenced  by  thickening  of  interalveolar  walls,  interlobular 
septa,  etc. 

Cavities  may  arise  (i)  in  dilated  bronchi  or  bronchioles  ; 
(2)  as  the  result  of  infection  of  a  caseous  area  with  pyogenic 
organisms,  and  so  the  softening  of  the  area ;  (3)  as  the  result 
of  the  bursting  of  a  caseous  area  into  a  bronchus. 

The  cavities  are  lined  with  breaking-down,  caseous  lung 
tissue.  Suitably  stained  preparations  will  demonstrate  tubercle 
bacilli  often  in  very  large  numbers,  both  in  catarrhal  pneumonic 
areas  and  in  caseous  foci  or  walls  of  cavities. 

The  vessels  are  often  involved  in  the  process,  and  blood 
infection  by  invasion  of  a  caseous  focus  into  a  vessel  is  not 
infrequent. 

3.  Fibro-caseous  Tuberculosis 

This  is  the  common  condition  found  in  cases  of  chronic 
pulmonary  tuberculosis.  It  passes,  on  the  one  hand,  by 
insensible  gradations  into  the  previous  more  acute  type  of  the 
disease.  On  the  other  hand,  with  increase  in  the  fibrous 
tissue  element,  it  passes  into  so-called  "  fibroid  phthisis." 
The  term  is  one  which  is  perhaps  not  the  best  possible,  but 
it  is  descriptive,  and  is  preferable  to  the  purely  clinical  one 
of  chronic  "  phthisis." 

The  condition  is  usually  complicated  by  cavitation.  Hence 
in  speaking  of  this  type  one  would  refer  to  it  as  fibro- 
caseous  tuberculosis  with  cavitation. 

Naked-eye  Appearances. — The  lung  shows  on  its  surface 
evidence  of  chronic  pleurisy.  It  is  usually  firmly  adherent 
to  the  chest  wall.  For  its  removal  it  is  advisable  to  strip 
the  parietal  pleura  from  the  ribs  in  the  way  described  on  p.  20. 
The  organ  is  distended,  and  on  palpation  it  will  be  found 


DISEASES  OF  THE  LUNGS  145 

partially  consolidated.  Usually  this  consolidation  is  more 
marked  towards  the  upper  part. 

On  cutting  into  the  lung  the  increase  in  consistence  will 
be  noted.  The  section  will  show  the  following  appearances 
(Fig.  53).  Towards  the  apex  of  the  upper  lobe  will  usually  be 
found  one  or  more  cavities,  one  of  which  commonly  is  distinctly 
larger  than  the  other,  varying  in  size  from  a  walnut  to  a 
tangerine  orange.  Indeed,  in  some  cases  the  cavity  may 
be  found  to  occupy  the  whole  of  the  upper  lobe.  The  walls 
of  the  cavity  are  formed  of  fibrous  tissue  and  are  often  com- 
paratively smooth.  Frequently  bronchi  and  vessels  of  con- 
siderable size  can  be  seen  crossing  the  cavity,  the  lung  tissue 
having  largely  disappeared  from  around  these  more  resistant 
structures.  Occasionally  aneurysms  may  be  found  on  the 
course  of  such  vessels  (Fig.  52). 

Throughout  the  remainder  of  the  lung  there  is  a  general 
increase  in  the  amount  of  fibrous  tissue.  From  the  thickened 
pleura,  thickened  interlobular  septa  can  be  seen  passing  in. 
The  vessels  and  bronchi  are  thickened.  This  thickening  is 
usually  more  marked  towards  the  root  of  the  lung.  The 
bronchi  are  not  infrequently  dilated,  their  walls  being  pulled 
upon  by  the  contracting  tissue  around.  They  show  evidence 
of  acute  bronchitis  and  contain  more  or  less  muco-purulent 
secretion. 

The  bronchial  glands  at  the  root  of  the  lung  are  enlarged 
and  show  caseous  or  calcareous  change. 

Around  the  cavity,  or  cavities,  the  lung  substance  is  largely 
consolidated  by  a  fibro-caseous  process.  On  analysis  it  will 
be  found  to  consist  of  firm  nodules,  larger  and  smaller,  which 
are  pigmented  and  show  caseous  change. 

In  advance  of  this  more  completely  consolidated  area,  i.e. 
in  the  lower  part  of  the  upper  lobe  and  in  the  lower  lobes, 
will  be  found  isolated  areas  of  consolidation  of  a  similar  type, 
having  a  staphyloid  arrangement  indicating  lymphatic  spread. 
In  addition,  there  are  often  areas  of  caseous  pneumonia, 


146    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

indicating  recent  acute  spread  of  the  disease.  The  presence 
of  the  latter  areas  suggests  "  aspiration  "  spread. 

As  a  rule,  in  such  chronic  cases  both  lungs  are  affected , 
one,  usually  the  right,  showing  the  more  advanced  lesions. 

Contraction  of  the  fibrous  tissue  in  the  various  parts  of 
the  lung  tends  to  occur,  pulling  upon  bronchi  and  air  vesicles. 
Dilation  is  thus  caused,  producing  bronchiectasis  or 
emphysema  (traction  emphysema),  as  the  case  may  be. 

The  above  appearances  are  found  mainly  in  tuberculosis 
of  adults,  but  similar  changes  are  occasionally  met  with  in 
children. 

This  type  of  the  disease  requires  to  be  distinguished  from 
the  other  interstitial  pneumonias,  more  especially  from 
syphilitic  disease  and  from  silicosis.  Again,  the  distribution 
of  the  disease — apical  in  the  case  of  tuberculosis,  at  the  root 
of  the  lung  or  under  the  pleura  in  the  case  of  syphilis — is  the 
chief  means  of  differentiation.  The  presence  of  cavities  is 
characteristic  only  of  tuberculosis,  although  it  should  be 
remembered  that  silicosis  maybe  accompanied  by  tuberculosis. 
Lastly,  the  nodules  in  silicosis  are  much  harder  and  have  a 
characteristic  gritty  feel. 

Microscopic  Appearances. — One  of  the  most  striking  changes 
is  the  increase  of  fibrous  tissue — thickening  of  pleura,  of  inter- 
lobular  septa,  thickening  round  vessels  and  bronchi.  The 
fibrous  tissue  in  these  structures  often  shows  a  marked  new 
development  of  elastic-tissue  fibres.  The  lung  substance  itself 
shows  irregular  consolidation  due  to  the  presence  of  numerous 
fibro-caseous  areas,  some  of  which  are  nodules  of  tuberculous 
granulation  tissue  displacing  the  lung  tissue.  Others  represent 
areas  of  caseous  pneumonia,  in  which  the  elastic  tissue  network 
in  suitably  stained  specimens  is  still  visible,  and  which  are 
surrounded  by  zones  of  fibrous  tissue.  The  blood  -  vessels 
generally,  more  particularly  those  in  the  neighbourhood  of 
cavities,  show  thickening  of  their  intima  as  well  as  adventitia. 
Some  have,  in  this  way,  their  lumen  completely  obliterated. 
In  others  the  closure  is  only  partial,  and  new  vessels  possessing 
their  own  elastic  laminae  develop  within  the  compass  of  the 


DISEASES  OF  THE  LUNGS  147 

old.  The  bronchi  show  evidence  of  catarrhal  inflammation, 
as  also  the  remaining  lung  alveoli.  The  lining  cells  of  the 
alveoli  are  often  cubical  instead  of  being  flat.  The  cavities 
are  lined  with  a  zone  of  granulation  tissue  or  of  well-formed 
fibrous  tissue.  The  vessels  in  the  neighbourhood  become 
partially  or  completely  occluded  by  the  occurrence  of  endarteritis 
obliterans.  In  suitably  stained  specimens,  tubercle  bacilli  may 
be  found,  but  they  are  commonly  very  few  and  scattered. 
They  occur  chiefly  in  the  walls  of  the  cavities  and  in  areas 
of  caseous  pneumonia. 

Changes  in  other  Organs  in  Cases  of  Pulmonary  Tuber- 
culosis.— In  cases  of  miliary  tuberculosis,  metastatic  foci 
are  found  in  liver,  spleen,  and  kidneys  as  in  the  lung. 
Acute  degenerative  changes,  such  as  cloudy  swelling  and 
early  fatty  change ,  will  be  seen  in  the  parenchymatous  organs, 
also  acute  congestion  of  the  spleen.  In  carrying  out  post- 
mortem examinations  upon  cases  of  miliary  tuberculosis 
careful  search  should  be  made  for  the  site  of  invasion  of  the 
vessel.  Attention  should  be  specially  directed  to  the  con- 
dition of  the  thoracic  duct  and  the  retroperitonal  lymph 
glands.  The  various  branches  of  the  pulmonary  artery 
within  the  lung  should  also  be  slit  up. 

In  the  more  usual  form  of  caseous  pneumonia  or  fibro- 
caseous  tuberculosis,  cloudy  swelling  and  fatty  change  in  such 
organs  as  heart,  liver,  and  kidneys  is  constantly  present. 
Not  infrequently  the  liver  is  greatly  enlarged  from  an  extreme 
degree  of  fatty  infiltration.  Waxy  disease  also  should  be 
sought  in  spleen,  liver,  kidneys,  etc.  Very  often  acute 
metastatic  spread  of  the  disease  occurs  terminally  in  these 
cases  also,  with  the  presence  of  miliary  foci  in  all  the  internal 
organs.  Intestinal  tuberculosis — ulceration  of  bowel  and 
caseous  mesenteric  glands — is  not  uncommon  as  a  secondary 
manifestation  due  to  the  swallowing  of  infected  sputum.  In 
the  more  chronic  forms  of  pulmonary  tuberculosis  the  right 
side  of  the  heart  will  be  found  hypertrophied  and  dilated, 


148   DISEASES  OF  THE  RESPIRATORY  SYSTEM 

and,  as  a  sequel,  chronic  venous  congestion  of  liver,  spleen,  etc. 
Tuberculous  meningitis  due  to  spread  of  the  disease  to  brain 
or  cord  is  a  common  termination  of  the  more  rapidly  pro- 
gressive cases. 

Careful  investigation  should  always  be  made  of  the  various 
groups  of  lymphatic  glands — cervical,  bronchial,  mesenteric — 
with  a  view  to  deciding  the  point  of  origin  of  the  disease. 
The  condition  of  the  bones  and  joints  should  also  be  looked 
into.  Finally,  in  investigating  cases  of  tuberculosis  where 
there  are  many  lesions  present,  with  a  view  to  determining 
the  site  of  origin  of  the  disease  (in  other  words,  the  oldest 
lesion),  the  following  points  should  be  attended  to:  (i) 
Nature  of  lesion — caseous  foci  are  always  older  than  grey, 
cellular  foci ;  calcareous  foci  are  older  than  caseous. 
Fibrosis  is  also  indicative  of  long-standing  disease.  (2) 
Extent  of  lesion — other  things  being  equal,  an  extensive 
lesion  is  older  than  a  small  one. 

Tumours  of  the  Lung. — Simple  growths  of  the  lung  are  very 
rare.  Malignant  growths  are  comparatively  common,  more 
especially  sarcomata,  but  primary  growths  of  a  malignant 
nature  are  rare.  Straining  as  they  do  the  whole  of  the  venous 
blood  of  the  body  which  has  not  been  strained  in  the  capillaries 
of  the  liver,  the  lungs  are  apt  to  be  the  seat  of  deposit  of 
metastatic  growths  which  invade  the  veins.  Thus  secondary 
growths  are  common.  Sarcomata  are  much  more  frequent  in 
the  lungs  than  carcinomata.  The  latter  occur,  but  in  appear- 
ance they  are  almost  indistinguishable  from  the  sarcomata. 
Another  common  type  of  growth  in  the  lung  is  a  sarcoma 
arising  in  the  glands  of  the  mediastinum  and  spreading  into 
the  lung  substance  by  direct  extension  (Fig.  56).  Occasionally 
the  growth  starts  in  the  pleural  surface,  and  either  remains 
limited  to  it  or  penetrates  the  lung. 

Naked-eye  Appearances. — The  growth  may  occur  in  the 
form  of  white  or  grey  isolated  nodules  (Fig.  55),  or  there  may 


DISEASES  OF  THE  PLEURA  149 

be  large  areas  of  lung  infiltrated  with  growth.  In  both 
instances  the  condition  is  not  very  easily  distinguished  from 
grey  hepatisation  or  tuberculosis,  especially  as  necrosis  is 
common  and  spread  along  the  lymphatics  of  vessels  and 
bronchi  can  be  seen.  In  the  case  of  growth,  however,  the 
infiltrated  areas  have  a  more  translucent  appearance,  due  to 
the  fact  that  they  are  formed  of  cellular  tissue.  Another 
point  of  distinction  is  that  cavitation  is  not  observed  in 
growths.  Also  it  should  be  remembered  that  the  seat  of 
election  in  tuberculosis  is  the  apex.  There  is  no  particular 
portion  of  the  lung  specially  liable  to  be  affected  by  growth 
unless  it  be  the  root. 

DISEASES  OF  THE  PLEURA 

Hydrothorax  or  Dropsy  of  the  Pleural  Cavity. — A 
slight  amount  of  free  fluid  is  a  common  finding  at  a  post- 
mortem. Where  there  is  any  large  quantity,  a  careful  note 
should  be  made  of  the  appearance,  distribution,  and  approxi- 
mate amount  of  the  fluid.  It  is  usually  pale,  clear,  and  straw- 
coloured,  and  has  a  specific  gravity  of  1009-1012.  On 
microscopic  examination  of  the  centrifugalised  deposit,  a 
few  endothelial  cells  and  lymphocytes  will  be  found.  As  a 
rule  the  fluid  is  situated  at  the  most  dependent  portion  of 
the  pleural  cavity,  but  accumulations  may  occur,  limited  by 
adhesions,  at  other  parts.  The  condition  of  hydrothorax 
is  found  in  cases  of  chronic  heart  and  kidney  disease,  where, 
as  a  rule,  there  is  dropsy  of  other  parts. 

Haematothorax,  or  blood  in  the  pleural  cavity,  is  a  rare 
occurrence.  Free  blood  is  only  found  in  connection  with 
injuries  to  the  lung  or  chest  wall  and  in  malignant  disease. 
Small  extravasations  of  blood  may  be  found  under  the  visceral 
pleura  in  acute  infections,  in  anaemias,  and  in  asphyxia. 

Pneumothorax,  i.e.  gas  or  air  in  the  pleural  cavity.  This 
may  be  due  to  a  wound  of  the  chest  wall  or  lung,  rupture  of  an 


150    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

acute  tuberculous  cavity,  of  healthy  lung  or  emphysematous 
lung  in  a  paroxysm  of  coughing.  It  may  also  be  due  to  the 
presence  of  gas-producing  organisms  in  the  pleura,  these 
organisms  coming  usually  from  a  ruptured  cesophageal  or 
gastric  ulcer,  or  spreading  through  the  diaphragm  from  a 
liver  abscess  or  peritonitis.  In  the  last  case  a  purulent  in- 
flammation of  the  cavity  is  present  as  well,  the  condition 
being  known  as  pyopneumothorax. 

In  all  the  above  conditions,  in  the  absence  of  adhesions 
which  would  bind  the  lung  to  the  chest  wall,  complete  collapse 
of  the  lung  occurs. 

Acute  Pleurisy. — This  condition  may  be  primary,  due 
to  spread  by  blood  or  lymph,  or  secondary,  due  to  extension 
from  lung,  pericardium,  mediastinum,  peritoneum,  etc. 
Three  types  of  the  condition  may  be  distinguished : — 

(1)  Dry  vrfibrinous,  where  there  is  little  or  no  free  fluid. 

(2)  Serous  or  sero-fibrinous ,  where  there  is  more  or  less 
free  fluid,  in  which  there  are  commonly  flakes  of  fibrin  floating. 

(3)  Purulent,  where  there  is  purulent  fluid. 
The  last  is  usually  known  as  empyema. 

Naked-eye  Appearances. — The  surface  of  the  lung  shows, 
over  a  larger  or  smaller  area,  a  rough  granular  or  thick  opaque 
white  or  yellow  deposit  (Fig.  54).  This  may  be  adherent  or 
easily  removed  according  to  the  duration  of  the  inflammatory 
process.  The  pleura  underneath  shows  injection  of  its 
vessels,  and  the  subjacent  lung  may  show  pneumonic  con- 
solidation, or  sometimes  abscess  formation.  If  the  fluid 
be  large  in  amount,  and  if  there  are  no  adhesions  binding  the 
lung,  the  organ  shows  collapse. 

In  the  case  of  empyemas  which  have  been  in  existence 
for  some  time,  there  is  usually  considerable  thickening  of 
both  parietal  and  visceral  pleura  (Fig.  41). 

Microscopic  Appearances. — The  vessels  of  the  pleura  are 
distended  with  blood.  There  is  a  fibrinous  coagulum  on  the 


DISEASES  OF  THE  PLEURA  151 

surface,  and  also  in  the  interstices  of  the  pleura,  in  the  meshes 
of  which  are  entangled  leucocytes,  chiefly  of  the  polymorpho- 
nuclear  variety  in  the  earlier  stages.  The  endothelial  cells  of 
the  pleural  surface  may  be  swollen  but  still  attached,  or  they 
may  be  thrown  off  and  occur  free  amongst  the  fibrin.  If  the 
condition  has  lasted  for  some  time,  there  is  evidence  of  organisa- 
tion— young  blood-vessels  budding  out  from  the  pre-existing 
ones  of  the  pleura,  and  young  connective-tissue  cells  ac- 
companying these  into  the  exudate.  These  latter  (fibroblasts) 
are  at  first  rounded,  and  possess  a  relatively  large  amount  of 
protoplasm.  Later  they  tend  to  become  spindle-shaped,  and 
eventually  to  arrange  themselves  parallel  to  the  pleural  surface. 
From  their  protoplasm,  fibres  are  split  off  which  form  the 
intercellular  fibres  of  the  new  tissue. 

In  empyemas  which  have  lasted  for  some  time  these  later 
changes  are  more  in  evidence. 

Chronic  Pleurisy. — This  is  a  very  common  condition, 
either  in  the  form  of  adhesions  between  lung  and  chest  wall, 
or  as  areas  of  thickened  pleura  without  adhesions.  It  is  a 
constant  occurrence  in  subacute  or  chronic  disease  of  the 
lung,  such  as  tuberculosis.  In  this  disease  the  pleura  may 
be  very  greatly  thickened,  as  much  as  one  inch  in  certain  cases. 

Microscopic  Appearances. — The  thickened  pleura  consists 
of  spindle-shaped  connective  tissue  cells  arranged  parallel  to 
the  surface  with  intervening  sinuous  collagenous  fibres.  Some- 
times these  latter  are  separated  more  or  less  widely  from  one 
another  owing  to  oedema.  Through  this  tissue  are  scattered 
a  few  wandering  (lymphocyte-like)  cells.  Running  at  right 
angles  to  the  surface  of  the  original  pleura  are  vessels  which 
vary  in  size  and  thickness. 

METHOD  OF  EXAMINING  A  LUNG  REMOVED  FROM  THE  BODY 

Look  in  the  first  place  at  the  shape  of  the  organ.  The  normal 
lung  will  become  flattened  on  being  placed  upon  a  table, 
whereas  the  consolidated  lung  (whether  the  consolidation  be 
due  to  fluid  or  solid  exudate  in  the  alveoli)  retains  its  rounded 
shape.  Note  the  size  of  the  organ.  An  organ  the  seat  of 


152    DISEASES  OF  THE  RESPIRATORY  SYSTEM 

emphysema  is  usually  more  voluminous  than  usual.  Weigh 
the  lung.  The  weight  of  the  normal  lung  is  about  i  Ib.  3  oz. 
to  i  Ib.  12  oz.  (538-764  grammes),  the  right  being  a  little 
heavier  than  the  left,  and  the  lung  of  the  male  somewhat 
heavier  than  that  of  the  female.  Examine  the  surface  of  the 
organ  for  exudate,  fibrous  thickening,  small  haemorrhages. 
Note  the  amount  of  pigment  present  at  the  points  where  the 
interlobular  septa  join  the  pleura.  Examine  the  margin  for 
evidence  of  emphysema  and  look  for  any  puckering  of  the 
surface,  especially  at  the  apex.  Next  feel  the  organ  carefully 
all  over,  searching  specially  for  any  hard  areas  which  would 
indicate  consolidation.  Note  the  distribution  of  the  firm  areas, 
whether  discrete  or  diffuse.  Incise  the  organ  longitudinally 
(see  p.  27)  and  examine  the  cut  surface  as  to  colour.  Note 
the  distribution  of  any  congested  areas.  Feel  the  surface 
carefully  and  squeeze  the  tissue  between  the  fingers,  noting  if 
any  fluid  escapes  and  the  character  of  such  fluid.  Any  areas 
of  consolidation  should  now  receive  more  careful  attention  as 
regards  colour,  distribution,  etc.  It  may  be  necessary  further 
to  incise  firm  nodules  or  areas  and  to  remove  portions  in  order 
to  ascertain  whether  they  sink  or  float  in  water.  Where  cavities 
are  present  their  position,  shape,  character  of  contents,  wall, 
and  surroundings  are  all  points  to  note.  The  large  bronchi 
should  then  be  opened  and  the  character  of  their  contents  and 
appearances  of  their  walls  noted.  The  bronchial  and  medi- 
astinal  glands  should  be  examined  as  to  size,  consistence, 
presence  of  grey  or  yellow  tubercles,  etc.  The  branches  of 
the  pulmonary  artery  should  be  slit  up  and  examined  for 
impacted  thrombi. 


CHAPTER   VIII 

DISEASES   OF  THE  INTESTINAL  TRACT  AND   PERITONEUM 

Diseases  of  Mouth,  Pharynx,  etc.  —  The  condition  of 
the  teeth  should  always  be  investigated.  The  presence  of 
caries  should  be  noted.  More  particularly  in  cases  of  severe 
anaemia,  suppuration  should  be  looked  for  in  the  mouth 
cavity.  Pyorrhoea  alveolaris  is  commonly  associated  with 
chronic  toxaemia  and  anaemia.  In  any  case  where  enlarge- 
ment  of  the  cervical  glands  is  present,  the  mouth  and  pharynx 
should  be  carefully  investigated  for  tumour  formation, 
suppurative  foci,  actinomycosis,  etc. 

In  diphtheria  the  tonsils  and  pharynx  should  be  examined 
for  false  membrane.  It  appears  as  grey  opaque  areas  sur- 
rounded with  congestion.  The  membrane  in  this  position 
is  not  easily  removed,  as  it  is  formed  of  the  covering  epithelium 
infiltrated  with  fibrinous  exudate.  In  any  suspicious  case 
not  diagnosed  during  life,  cultures  on  blood  serum  as  well  as 
films  should  be  made. 

Diseases  of  the  (Esophagus.  —  When  any  condition 
affecting  the  oesophagus  is  suspected,  as  in  poisoning,  dys- 
phagia,  hsematemesis,  care  should  be  taken  to  remove  the 
viscus  entire  along  with  the  pharynx  and  stomach.  This 
can  best  be  done  by  removing  tongue,  pharynx,  contents 
of  chest  and  abdomen  in  one  piece  as  described  on  p.  23 
and  then  removing  the  individual  organs  as  required,  opening 

i53 


154  DISEASES  OF  THE  STOMACH 

the  oesophagus  from  behind  and  examining  it  in  continuity 
with  the  stomach. 

The  oesophagus  is  not  infrequently  the  seat  of  varicose 
veins  in  cirrhosis  of  the  liver.  This  is  due  to  the  fact  that  the 
veins  from  the  lower  part  of  the  oesophagus  drain  indirectly 
into  the  portal  vein,  which  in  cirrhosis  of  the  liver  is  obstructed. 
The  cesophageal  veins  dilate  and  become  varicose.  Such 
veins  may  rupture,  and  severe,  even  fatal,  haemorrhage  result. 

The  oesophagus  suffers  along  with  the  stomach  in  corrosive 
poisoning,  and  presents  much  the  same  appearance  as  that 
organ  (see  p.  312).  Rarely  it  may  be  the  seat  of  peptic  ulcer  in 
its  lower  part.  Such  an  ulcer  may  rupture  into  one  or  other 
pleural  cavity  and  cause  a  pyopneumothorax. 

Tumours  of  the  oesophagus  are  occasionally  found,  by  far 
the  most  common  being  squamous  epitheliomata.  Very  infre- 
quently leio-myomata  are  found.  The  squamous  epithelioma 
of  the  oesophagus  is  found  in  the  form  of  an  ulcer  with 
raised  infiltrating  margin.  It  tends  to  form  a  ring-shaped 
area  of  constriction,  and  is  situated  either  high  up  about  the 
level  of  the  cricoid  cartilage,  low  down  near  the  cardiac 
orifice  of  the  stomach,  or  at  the  level  of  the  bifurcation  of 
the  trachea  (Fig.  57).  The  ulcer  may  extend  deeply,  perforat- 
ing the  trachea,  bronchi,  one  or  other  pleural  cavity,  or  peri- 
cardial  sac. 


DISEASES  OF  THE  STOMACH 

Owing  to  the  action  of  the  digestive  juices  of  the  organ 
itself,  and  owing  to  decomposition  in  its  contents  and  in  the 
contents  of  the  neighbouring  viscera,  the  stomach  undergoes 
considerable  changes  after  death,  and  the  longer  the  sectio 
is  delayed  the  greater  will  be  those  changes.  Blood  tends 
to  accumulate  in  the  vessels  of  the  organ  at  its  more 
dependent  parts,  giving  the  appearance  of  congestion,  and 
even  of  haemorrhage.  As  the  result  of  decomposition  in  this 


DISEASES  OF  THE  STOMACH  155 

blood,  green  discoloration  takes  place.  Frequently  there  is 
softening  of  the  wall  owing  to  digestion  by  the  gastric  juice. 
This  may  occur  to  the  extent  of  causing  actual  perforation. 
Obviously,  therefore,  care  must  be  taken  in  interpreting 
changes  found  in  the  stomach  post-mortem.  Changes  such 
as  softening  when  they  occur  before  death  tend  to  be  diffuse 
in  their  distribution,  whereas  post-mortem  softening  is  found 
mainly  in  the  more  dependent,  and  therefore  posterior,  part 
of  the  viscus. 

Dilatation  of  the  Stomach.  —  Gastrectasis.  —  Acute 
dilatation  may  be  due  to  the  ingestion  of  excessively  large 
quantities  of  food,  or  it  may  be  nervous  in  origin,  sometimes 
following  surgical  operations. 

Chronic  dilatation  may  be  due  to  (i)  narrowing  of  the 
pylorus  from  tumour,  (2)  the  presence  of  abnormal  contents 
from  fermentation  and  atony  of  the  muscular  wall  associated 
with  chronic  catarrh. 

Contractions  of  the  Stomach.  —  Narrowing  of  the 
pyloric  orifice  (congenital  pyloric  stenosis)  through  thickening 
of  the  muscular  coat  is  a  somewhat  rare  condition. 
Localised  contraction  of  the  organ  may  occur  as  a  sequel  to 
ulceration.  It  tends  to  produce  the  condition  of  "  hour- 
glass" stomach. 

Chronic  Venous  Congestion.  —  In-  chronic  valvular 
disease  of  the  heart,  chronic  lung  and  liver  disease,  passive 
hypersemia  tends  to  occur  in  the  stomach  as  in  other  organs. 
It  is  usually  associated  with  the  appearances  of  chronic 
catarrh,  accompanied  by  congestion  of  the  vessels  of  the 
mucous  membrane.  Minute  haemorrhages  may  occur,  and 
these  may  be  followed  by  small  superficial  ulcerations 
(hcemorrhagic  erosions). 

Acute  Catarrh  of  the  Stomach  may  occur  as  the  result 
of  (i)  dietetic  errors  ;  (2)  the  ingestion  of  irritant  or  corrosive 
poisons  ;  (3)  in  the  course  of  infective  fevers. 


156  DISPOSES  OF  THE  STOMACH 

Naked-eye  Appearances. — In  slight  cases  there  may  be 
little  or  no  alteration.  In  severe  cases  the  walls  of  the  viscus 
are  swollen,  the  mucous  membrane  congested,  and  covered 
with  strings  of  sticky  mucus.  Small  haemorrhages  may 
occur.  Where  the  cause  has  been  one  of  the  corrosive 
poisons  there  may  be  necrosis  and  sloughing  of  the  mucous 
membrane,  sometimes  with  perforation.  In  the  case  of 
certain  poisons  characteristic  colouring  may  be  present.  For 
further  information  on  the  appearances  of  the  stomach  in 
cases  of  poisoning  see  pp.  311-13. 

Microscopically,  the  vessels  of  the  wall  are  dilated.  There 
is  shedding  of  the  superficial  epithelium,  and,  in  the  more 
severe  varieties,  necrosis.  The  wall  is  infiltrated  with  inflam- 
matory cells  and  exudate  from  the  vessels. 

Acute  Suppurative  Gastritis  sometimes  occurs  in  the 
course  of  specific  fevers  and  pyaemia  or  as  the  result  of  spread 
of  inflammation  from  neighbouring  parts.  The  portion  of 
the  wall  affected  is  thickened,  pale  yellow  in  colour,  and 
found,  on  microscopic  examination,  to  be  infiltrated  with 
fibrin  and  leucocytes.  The  mucous  membrane  superficial 
to  the  area  shows  acute  catarrh,  and  sometimes  exudate. 

Chronic  Catarrh. — This  may  follow  acute  catarrh  or 
develop  independently.  It  is  frequent  in  chronic  alcoholics, 
and  occurs  in  association  with  chronic  venous  congestion, 
peptic  ulcer,  and  carcinoma. 

The  stomach  is  usually  dilated.  The  mucous  membrane 
is  pale  and  atrophied.  There  may  be  scattered  small  haemor- 
rhages or  pigmented  black  areas  following  such.  The  surface 
of  the  mucous  membrane  is  covered  with  thick  sticky  mucous 
secretion.  Small  follicular  ulcers  may  be  present.  These 
ulcers  are  shallow  with  undermined  edges.  They  may  heal, 
leaving  a  small  puckered  scar. 

Microscopically,  beyond  some  overgrowth  of  fibrous  tissue, 
catarrh  of  the  gland  cells,  and  infiltration  of  the  coats  with 
round  cells,  there  is  little  to  be  seen. 


DISEASES  OF  THE  STOMACH  157 

Peptic,  Perforating,  or  Chronic  Ulcer. — This  condition 
is  found  more  frequently  in  females  than  in  males.  It  is  chiefly 
found  in  young,  anaemic  girls  between  the  ages  of  twenty  and 
thirty.  It  may  be  associated  with  chronic  gastric  catarrh. 

The  ulcer  is  commonly  single,  but  occasionally  there  is 
more  than  one.  It  is  situated  usually  on  the  posterior 
wall  near  the  lesser  curvature,  and  nearer  the  pylorus  than 
the  cardia.  About  i  per  cent  occur  on  the  anterior  wall. 
The  ulcer  varies  in  size.  Usually  it  is  about  the  size  of  a 
sixpence,  but  it  may  be  much  larger.  The  margins  of  the 
ulcer  are  rounded,  smooth,  and  devoid  of  evidence  of  inflam- 
mation, presenting  a  punched-out  appearance  (Fig.  58).  The 
floor  may  be  formed  by  one  of  the  coats  of  the  stomach,  but  not 
infrequently  it  is  formed  of  fibrous  tissue,  or  of  one  or  more 
of  the  organs  behind  the  stomach,  such  as  pancreas  or  liver. 

Owing  to  the  fact  that  the  opening  in  the  mucous  membrane 
is  larger,  the  opening  in  the  muscular  coat  smaller,  the  ulcer 
may  show  a  terraced  appearance.  The  associated  chronic 
inflammation  in  the  wall  of  the  viscus  causes  the  formation 
of  adhesions  to  structures  lying  posterior ;  hence  with  increase 
of  depth  these  organs  become  exposed  in  the  floor  of  the 
ulcer.  Not  infrequently,  however,  before  such  adhesions 
can  form  perforation  occurs.  In  the  case  of  the  ulcer  on  the 
posterior  wall  this  will  take  place  into  the  lesser  sac  of  the 
peritoneum.  The  acute  peritonitis  resulting  is  thus,  at  first, 
limited.  In  the  case  of  the  anterior  ulcer,  perforation  occurs 
more  rapidly,  and  takes  place  directly  into  the  peritoneal 
cavity,  causing  a  general  peritonitis.  Healing  may  take 
place,  associated  with  cicatrisation  and  sometimes  the  forma- 
tion of  an  "  hour-glass "  stomach.  Besides  perforation, 
another  accident  which  may  occur  is  hcemorrhage  due  to 
erosion  of  a  vessel  in  the  wall  of  the  stomach,  or  possibly  one 
of  the  larger  vessels  lying  behind  the  organ. 

A  similar  type  of  ulcer  is  sometimes  found  in  the  duodenum 
immediately  beyond  the  pylorus.  It  resembles  the  peptic 


158  DISEASES  OF  THE  STOMACH 

ulcer  of  the  stomach  in  every  respect  except  that  it  is  more 
frequent  in  the  male  sex.  As  a  rule  the  ulcer  is  small,  but  it 
may  attain  a  large  size  (Fig.  59).  As  in  the  case  of  the  stomach 
ulcer,  the  floor  may  be  formed  by  fibrous  tissue  or  by  an  organ 
such  as  the  pancreas.  Perforation  and  haemorrhage  are 
accidents  not  infrequently  met  with  in  this  case  also. 

The  causation  of  both  types  of  ulcer  is  obscure.  Throm- 
bosis occurring  in  a  vessel  supplying  the  mucous  membrane, 
with  consequent  malnutrition  and  then  digestion  by  the 
juices  within,  has  been  suggested  as  an  explanation  of  their 
occurrence. 

Fibromatosis. — Occasionally  the  stomach  is  the  seat  of 
a  diffuse  fibrous  overgrowth  implicating  chiefly  the  sub- 
mucous  and  muscular  coats,  and  commonly  associated  with 
a  chronic  ulcer.  This  condition,  which  is  usually  most  marked 
at  the  pyloric  end  of  the  organ,  has  been  called  fibromatosis. 
It  is  sometimes  mistaken  for  malignant  new  growth. 

Tumours. — Simple  tumours  of  the  stomach  are  rare. 
Fibromata,  myomata,  adenomata  are  described.  Mucous 
papillomata  also  occur. 

Of  malignant  tumours,  sarcomata  are  uncommon. 

Carcinoma.-^- This  is  the  common  stomach  tumour.  It 
is  most  frequently  situated  at  the  pyloric  end  (60  per  cent). 
The  next  most  frequent  site  is  the  lesser  curvature  (20  per 
cent).  Abo.ut  10  per  cent  occur  at  the  cardiac  orifice  (Fig.  60). 
As  regards  the  type  of  cancer  found,  the  most  common  is 
the  encephaloid  variety  of  the  adeno-carcinoma.  The  next 
most  common  is  the  scirrhous,  then  the  colloid,  and  least 
frequent  is  the  squamous  epithelioma,  which  is  occasionally 
found  at  the  cardiac  end. 

The  tumour  may  lead  to  a  localised  or  diffuse  thickening 
of  the  stomach  wall.  More  frequently  there  is  an  ulcerated 
surface  with  a  raised,  hard,  infiltrated  margin.  Sometimes 
the  growth  projects  into  the  interior  of  the  viscus  as  a  cauli- 


DISEASES  OF  THE  INTESTINE  159 

flower-like  mass  (Fig.  60).  The  floor  is  formed  of  necrosed 
tumour  substance.  Perforation  rarely  occurs.  Secondary 
deposits  are  very  commonly  found  in  the  neighbouring  glands 
and  in  the  liver. 

DISEASES  OF  THE  INTESTINE 

Malformations. — MeckePs  diverticulum  is  a  finger-like 
cul-de-sac,  the  remains  of  the  omphalo  -  mesenteric  duct, 
usually  2-3  inches  in  length,  occurring  some  2  or  3  feet 
above  the  ileo-csecal  valve.  It  is  sometimes  attached  to  the 
umbilicus.  It  may  become  closed  and  give  rise  to  cyst  or 
abscess  formation,  or  it  may  become  adherent  to  the  parietes, 
thus  forming  a  band  under  which  a  loop  of  bowel  may 
become  strangulated. 

Smaller  diverticula  may  be  found  in  connection  with 
other  parts  of  the  small  intestine,  such  as  the  duodenum, 
and  pouches  between  the  layers  of  the  mesentery  may  be 
found. 

Dilatation  of  the  bowel  is  found  as  the  result  of  peri- 
tonitis (paralytic  distention),  constipation,  obstruction  from 
strangulation,  infarction  or  tumour  formation.  When  the 
obstruction  is  long-continued  the  wall  of  the  bowel  above 
shows  hypertrophy  (Fig.  69). 

A  condition  of  dilatation  of  the  large  intestine,  more 
especially  the  ascending  colon,  associated  with  hypertrophy 
of  the  muscular  coat,  known  as  Hirschspmng's  disease, 
occasionally  occurs.  It  is  believed  to  be  congenital. 

Stenosis,  or  narrowing  of  the  bowel,  may  be  due  to  con- 
traction associated  with  ulceration  (especially  tuberculous), 
tumour  formation,  or  chronic  peritonitis. 

Volvulus  is  a  condition  in  which  the  bowel  is  obstructed 
by  a  loop  of  intestine  becoming  twisted  upon  itself.  Half  the 
cases  occur  in  the  pelvic  colon.  An  abnormally  long  mesentery 


160  DISEASES  OF  THE  INTESTINE 

predisposes  to   its  occurrence.      The   blood-supply  of  the 
portion  of  gut  is  interfered  with  and  gangrene  tends  to  occur. 

Intussusception  is  a  condition  in  which  a  portion  of  the 
bowel  is  invaginated  into  the  section  immediately  below. 
It  occurs  chiefly  in  infants,  and  is  believed  to  be  caused  by 
violent  peristalsis  due  to  active  purgation  or  diarrhoea.  The 
condition  may  occur  in  the  ileum  or  the  colon,  or  at  the 
ileo-csecal  valve.  The  portion  of  bowel  involved  forms  a 
sausage-shaped  tumour  (Fig.  61).  Pressure  on  the  mesentery 
of  the  intussuscepted  portion  causes  interference  with  its 
circulation  and  a  tendency  to  gangrene. 

A  similar  condition,  easily  reduced  and  often  multiple,  is 
not  infrequently  found  post-mortem.  It  is  believed  to 
develop  very  shortly  before  death.  In  this  type  there  is,  of 
course,  no  congestion  of  the  intussuscepted  portion,  and  there 
are  no  adhesions  between  the  various  layers  of  gut. 

Hernia. — A  hernia  is  usually  defined  as  a  condition  in 
which  there  is  a  protrusion  of  any  of  the  abdominal  contents 
from  the  cavity  of  the  abdomen.  The  term  is  also  used  in 
connection  with  the  rare  occurrence  of  a  protrusion  of  gut 
through  an  opening,  such  as  the  foramen  of  Winslow,  within 
the  abdomen. 

As  a  rule  it  is  either  a  portion  of  bowel  or  a  portion  of 
amentum,  or  both,  which  protrudes.  Occasionally  it  may  be 
a  Meckel' s  diverticulum  or  an  organ  such  as  liver,  spleen,  or 
stomach.  The  sac  of  the  hernia  is  usually  lined  by  peritoneum, 
although  this  may  disappear. 

The  condition  may  be  congenital,  the  sac  being  formed  by  a 
diverticulum  of  the  peritoneum  such  as  the  processus  vaginalis. 
More  usually  it  is  acquired  through  increased  abdominal 
pressure  from  coughing,  crying,  straining,  or  through  weak- 
ness of  the  abdominal  wall,  or  from  these  two  factors  combined. 
It  may  also  be  due  to  violence,  such  as  a  crush  driving  some 
of  the  abdominal  contents  through  the  diaphragm. 


DISEASES  OF  THE  INTESTINE  161 

The  protrusions  are  found  at  points  of  weakness  in  the 
abdominal  wall,  usually  where  vessels  enter  and  leave.  The 
commonest  type  is  the  inguinal  hernia  which  occurs  in  the 
inguinal  canal  and  may  be  congenital  or  acquired.  The 
second  commonest  type  is  the  femoral  hernia,  a  projection 
through  the  femoral  ring.  In  addition,  there  is  an  umbilical 
type  found  at  the  umbilicus  which  may  be  congenital  or 
acquired.  The  latter  type  is  found  chiefly  in  very  fat  women. 
Certain  rarer  forms  are  occasionally  met  with,  such  as 
obturator  hernia,  also  hernise  through  the  abdominal  wall  at 
points  which  have  been  weakened  by  scars  following  opera- 
tions. 

The  condition  is  not  of  much  importance  to  the  morbid 
anatomist.  Hernise  are  not  infrequently  met  with  by 
accident  at  a  post-mortem.  Strangulation  of  the  hernia,  i.e. 
interference  with  the  circulation  of  blood  through  the  gut 
with  consequent  acute  congestion  and  sometimes  gangrene, 
is  a  cause  of  acute  peritonitis,  but  it  is  rarely  seen  post-mortem. 
Internal  hernise,  e.g.  hernise  through  the  diaphragm,  are 
sometimes  met  with  as  the  result  of  severe  crushing  of  the 
abdomen. 

Chronic  Venous  Congestion  of  the  bowel  is  found  in 
cirrhosis  of  the  liver  and  in  chronic  heart  and  lung  disease. 
There  is  swelling  and  congestion  of  the  wall  of  the  gut, 
especially  of  the  mucous  membrane.  A  degree  of  catarrhal 
inflammation  is  very  constantly  associated. 

Infarction  of  a  portion  of  bowel,  most  frequently  of  that 
part  supplied  by  the  superior  mesenteric  artery,  is  sometimes 
found.  It  should  be  looked  for  in  cases  which  die  with 
symptoms  of  intestinal  obstruction.  The  portion  of  gut 
involved  is  deep  purple  in  colour,  and  usually  shows  peri- 
tonitis on  its  surface.  The  aorta  and  its  branches  should  be 
slit  up  to  find  the  point  where  the  block  occurred.  Careful 
search  should  be  made  for  a  possible  source  of  the  embolus, 

ii 


162  DISEASES  OF  THE  INTESTINE 

e.g.  a  thrombus  on  an  atheromatous   patch  of  the  aorta, 
or  in  the  left  side  of  the  heart  (see  diag.  p.  62). 

Haemorrhage  occurs  into  the  mucous  membrane  of  the 
bowel  in  the  form  of  small  extravasations  in  cases  of  infective 
diseases,  anaemias,  etc. 

Large  haemorrhages  may  occur  from  ulcerated  surfaces, 
such  as  duodenal  or  typhoid  ulcers.  The  blood,  mixed  with 
faecal  matter,  tends  to  undergo  alteration  into  a  black  mass 
of  putty-like  consistence  which  can  be  seen  through  the  wall 
of  the  gut  before  it  is  opened. 

INFLAMMATION  OF  THE  SMALL  INTESTINE- 
ENTERITIS 

Acute  Catarrhal  Enteritis  may  be  caused  by  irritating 
foods,  poisons,  dust,  by  normal  bacterial  inhabitants  of  the 
bowel,  such  as  B.  coli  or  streptococci,  or  by  specific  bacteria 
such  as  B.  typhosus  and  Vib.  cholera. 

Naked-eye  Appearances. — These  are  often  unsatisfactory. 
The  clinical  symptoms  are  frequently  out  of  all  proportion 
to  the  pathological  findings.  Usually  there  is  some  conges- 
tion of  the  vessels  of  the  mucous  membrane,  which  is  more 
or  less  swollen.  This  congestion  may  be  diffuse  or  patchy. 
Often  it  is  most  marked  at  the  apices  of  the  folds  in  the 
mucous  membrane.  When  due  to  the  action  of  a  micro- 
organism the  changes  are  commonly  more  marked  in  the  lower 
part  of  the  ileum.  In  cases  of  poisoning,  on  the  other  hand, 
the  duodenum  and  upper  part  of  the  jejunum  in  addition 
to  the  stomach  are  the  parts  most  affected,  although  it 
must  be  noted  that  irritant  poisoning  often  causes  little 
change  (see  p.  313).  Not  infrequently  the  lymph  follicles 
of  the  bowel  are  swollen  (follicular  enteritis)  and  may  ulcerate 
(follicular  ulcers).  The  mucous  membrane  may  be  covered 
with  viscid  mucus.  Sometimes  there  is  a  distinct  membrane 
formed  of  exudate  (membranous  enteritis).  Occasionally, 


DISEASES  OF  THE  INTESTINE  163 

in  the  more  intense  forms,  the  mucous  membrane  may 
undergo  necrosis,  forming  a  greenish  slough.  Small  embolic 
abscesses  may  be  found  in  pyaemia,  or  there  may  be  a  general 
infiltration  of  the  wall  of  the  gut  with  pus  (suppurative 
enteritis). 

Microscopic  Appearances. — There  is  dilatation  of  the  vessels 
of  the  bowel,  infiltration  of  the  wall  with  inflammatory  cells 
and  exudate  ;  increase  of  the  lymphoid  elements  and  swelling 
of  the  endothelial  cells  in  the  solitary  glands ;  catarrh  of  the 
superficial  epithelium.  In  suppurative  enteritis  small  abscesses 
and  more  intense  inflammatory  infiltration  are  found. 


SPECIAL  FORMS  OF  ENTERITIS 

1.  Cholera. — The  changes  are  most  marked  in  the  lower 
portion  of  the  ileum.    There  is  intense  swelling  and  conges- 
tion of  the  mucous  membrane.    The  lymphoid  follicles  may 
be  swollen  and  pale.    Small  haemorrhages  may  be  present. 
Membranous  enteritis  may  occur,  due  to  the  exudation  of 
fibrin  on  the  surface  of  the  mucous  membrane.    The  contents 
of  the  bowel  are  pale  and  watery  (rice  water). 

Microscopically,  there  is  marked  catarrh  of  the  epithelium, 
possibly  exudate  on  the  mucous  membrane,  and  infiltration  of 
the  wall  of  the  bowel  with  inflammatory  cells.  The  specific 
organisms  do  not  penetrate  the  wall  for  any  distance,  but 
they  are  found  in  immense  numbers  along  with  desquamated 
epithelial  cells  in  the  rice-water  contents  of  the  bowel. 

2.  Typhoid. — In  this  condition  also  the  change  is  most 
marked  in  the  lowest  portion  of  the  ileum.    It  consists,  in  the 
early  stage,  in  a  swelling,  of  the  lymphoid  tissue  generally, 
both  Peyer's  patches  and  solitary  follicles  (Fig.  62).    These 
areas  are  pale,  but  the  bowel  between  may  show  congestion. 
At  about  the  beginning  of  the  second  week  of  the  disease, 
necrosis  commences  in  these  swollen  accumulations  of  lymph- 
oid tissue  (Fig.  63).     In  this  way  sloughs  form  which  take 


164  DISEASES  OF  THE  INTESTINE 

on  a  yellow  or  green  colour  from  bile  staining.  These  sloughs 
separate  towards  the  end  of  the  third  week  of  the  disease  and 
ulcers  are  left  which  have  the  following  characters  : — The 
larger  ones,  representing  as  they  do  an  ulcerated  Peyer's 
patch,  are  usually  in  the  longitudinal  direction  of  the  bowel ; 
during  the  separation  of  the  sloughs  hczmorrhage  tends  to 
occur.  The  smaller  ones,  representing  the  solitary  follicles, 
are  rounded.  The  edges  of  the  ulcers  are  ragged  and  over- 
hanging. The  floor  is  formed  of  one  of  the  coats  of  the  bowel 
— the  submucous,  muscular,  or  peritoneal.  Perforation  is  not 
infrequent.  The  peritoneal  aspect  of  the  portion  of  bowel 
may  show  evidence  of  acute  inflammation  by  injection  of 
vessels  and  even  fibrinous  exudate. 

Occasionally,  in  cases  dying  from  complications  late  in 
the  disease,  the  ulcers  may  be  found  in  process  of  cicatrisa- 
tion. 

In  a  case  of  typhoid  fever,  in  addition  to  the  condition 
of  the  intestine,  attention  should  be  paid  to  (i)  the  mesenteric 
glands,  which  are  constantly  enlarged,  congested,  and  may 
show  haemorrhages  and  necrotic  foci ;  (2)  the  spleen,  which 
shows  acute  congestion,  and,  microscopically,  areas  of  focal 
necrosis ;  (3)  the  liver,  with  cloudy  swelling  and  areas  of  focal 
necrosis ;  (4)  the  kidneys  and  heart,  which  show  cloudy 
swelling ;  (5)  in  contrast  to  most  cases  of  infective  disease, 
the  bone  marrow,  in  uncomplicated  cases,  shows  little  or  no 
evidence  of  leucoblastic  reaction. 

Cultures  should  be  made  from  the  common  bile  duct,  the 
spleen,  or  the  contents  of  the  small  intestine  (see  p.  360). 

Microscopic  Appearances. — In  the  stage  of  swelling,  separa- 
tion of  the  cell  elements  of  the  Payer's  patch  due  to  oedema  is 
found.  There  is  also  swelling  and  proliferation  of  the  endo- 
thelial  cells  of  the  lymphoid  tissue  and  catarrh  of  the  mucous 
membrane  generally.  Bacilli  may  be  found  in  groups  in  the 
swollen  patch.  Necrosis  begins  in  areas  at  the  centre  of  the 
Peyer's  patch  and  spreads.  The  typhoid  ulcer  merely  shows 


DISEASES  OF  THE  INTESTINE  165 

the  appearance  of  an  acute  ulcer  with  overhanging  edges, 
floor  formed  of  muscular  coat  as  a  rule.  Inflammatory  changes 
are  present  in  muscular  coat  and  tissue  around.  In  suitably 
stained  specimens  bacilli  are  found  in  masses,  both  superficially 
and  deep  in  the  wall. 

The  mesenteric  glands,  in  addition  to  the  appearance  of  an 
acute  lymphadenitis — swelling  and  loosening  of  endothelial 
cells  of  sinuses,  etc. — show  areas  of  necrosis  and  haemorrhage, 
with  occasional  masses  of  bacilli. 

3.  Tuberculosis.  —  This  is  usually  secondary  to  tuber- 
culosis of  the  lungs,  the  intestine  becoming  infected  by  the 
swallowing  of  sputum  containing  tubercle  bacilli.  As  a 
primary  condition  of  the  bowel,  the  disease  is  comparatively 
rare,  although  it  has  been  found  in  as  large  a  proportion  as 
12  per  cent  of  all  cases  of  tuberculosis. 

Tuberculosis  of  the  mucous  membrane  of  the  bowel  is, 
however,  by  no  means  necessarily  found  in  cases  where  the 
intestine  is  the  path  of  entrance  of  the  tubercle  bacillus. 
The  disease  may  show  itself  first  in  the  mesenteric  glands  or 
in  the  peritoneum,  no  demonstrable  lesion  of  the  bowel 
itself  being  present. 

Naked-eye  Appearances. — The  part  commonly  affected  is, 
as  in  typhoid,  the  lower  portion  of  the  ileum.  The  earliest 
lesion  consists  in  a  tubercle  nodule  underneath  the  mucous 
membrane.  Ulceration  occurs  over  this,  and  tends,  owing 
to  the  distribution  of  the  lymphatics  of  the  bowel,  to  spread 
laterally,  often  encircling  the  bowel,  with  the  exception  of  that 
portion  over  the  attachment  of  the  mesentery.  The  appear- 
ances in  the  fully  developed  ulcer  are  as  follows  (Fig.  64) :  the 
direction  is  transverse  to  that  of  the  bowel,  although  this 
character  is  by  no  means  constant ;  the  edge  is  irregular, 
nodular,  but  rounded  ;  the  floor  is  formed  of  tuberculous 
granulation  tissue  ;  the  peritoneal  aspect  shows  opaque  white 
thickening  of  the  wall,  the  presence  of  tubercle  nodules  (Fig. 
65)  under  the  peritoneum,  and  sometimes  white  lines  of 


i66 


DISEASES  OF  THE  INTESTINE 


injected  lymphatics  radiating  from  the  area.  Constriction 
of  the  bowel  is  common,  as  also  is  adhesion  to  surroundings. 

Perforation  is  a  comparatively  rare  occurrence  in  tuber- 
culous ulceration,  as  also  is  haemorrhage. 

The  mesenteric  glands  are  constantly  enlarged  and  show 
caseous  areas  or  grey  granulations,  occasionally  calcification. 

Microscopic  Appearances. — At  the  margins  of  the  ulcer,  in 
the  floor,  often  replacing  the  muscle  substance,  and  under  the 
peritoneal  coat,  there  are  tubercle  granulations  with  giant-cell 
or  caseous  centres.  Tubercle  bacilli  are  not,  as  a  rule, 
numerous. 

TUBERCULOSIS  AND  TYPHOID  ULCERS  CONTRASTED  AS 
REGARDS  THEIR  NAKED-EYE  APPEARANCES 


Tuberculous  Ulcer. 

Typhoid  Ulcer. 

Direction  . 

Typically  transverse. 

Typically  longitudinal. 

Margin 

Raised,  rounded,  nodular. 

Overhanging,  ragged. 

Floor   .     . 

Irregular,  formed  of  tuber- 
culous granulation  tissue. 

Smooth,  formed  of  one  of 
the  coats  of  the  bowel. 

Peritoneal 
aspect 

Raised,  grey  or  yellow 
tubercles.  Thickening 
and  sometimes  constric- 
tion. Perforation  rare. 
Adhesions  frequent. 

Evidence  of  acute  inflam- 
mation, congestion,  exu- 
date.  Perforation  fre- 
quent. No  adhesions 
or  constriction. 

Associated 
mesenteric 
glands 

Enlarged  and  firm,  caseous. 
Sometimes  calcareous. 

Enlarged,  congested  with 
necrotic  foci,  soft. 

4.  Syphilis. — This  is  a  rare  condition.     It  may  occur  in 
the  form  of  gummata,  ulceration,  or  cicatrisation  with  stenosis. 

5.  Actinomycosis. — This  is  also  rare.    It  may  affect  the 


intestine  or  appendix, 
in  the  liver. 


Secondary  abscesses  usually  occur 


DISEASES  OF  THE  INTESTINE  167 


INFLAMMATION  OF  THE  LARGE  INTESTINE 

In  its  slighter  forms  this  condition  is  known  as  colitis, 
in  its  more  severe  forms  as  ulcerative  colitis  or  dysentery. 

As  regards  causation,  (i)  the  slighter  forms  of  the  disease 
may  be  due  to  indiscretions  of  diet,  chill,  germs  of  various 
kinds.  Of  the  more  severe  types,  two  varieties  are  dis- 
tinguished :  (2)  Bacterial  Dysentery,  with  which  organisms 
closely  related  to  B.  coli,  e.g.  Shiga's  bacillus  and  Flexner's 
bacillus,  are  more  especially  associated;  (3)  Tropical  Dysen- 
tery, generally  believed  to  be  caused  by  a  protozoon,  the 
Entamceba  histolytica. 

(1)  The  milder  types  of  inflammation  show  congestion 
of  the  mucous  membrane,  some   cedema,  swelling  of  the 
lymphoid  follicles, and,  sometimes,  slight  superficial  ulceration. 

Microscopically,  beyond  catarrh  of  the  mucous  membrane, 
congestion  of  vessels,  and  infiltration  of  the  coats  with  inflam- 
matory cells,  there  is  little  to  be  seen. 

(2)  Ulcerative  Colitis  or  Bacterial  Dysentery. — The  wall 
of  the  bowel  is  usually  thickened.    On  opening  the  gut  there 
is  irregular  ulceration  with  tags  of  thickened  mucous  membrane 
between  the  ulcers  (Fig.  66).    These  tags  often  occur  in  longi- 
tudinal ridges.    The  edges  of  the  ulcers  are  overhanging,  and 
the  floor  is  usually  formed  by  the  submucous  or  muscular  coat. 
Occasionally,  destruction  of  the  muscular  coat  is  found,  and 
sometimes  perforation. 

Microscopic  Appearances. — There  is  catarrh  of  the  mucous 
membrane  and  thickening  of  the  submucous  and  muscular 
coats.  These  are  infiltrated  with  inflammatory  cells  and 
exudate,  and  there  is  marked  swelling  of  the  endothelial  cells 
of  the  lymphatics  and  vessels. 

The  above  description  holds  good  more  especially  for  the 
type  of  the  disease  found  in  Great  Britain.  In  the  type 


168  DISEASES  OF  THE  INTESTINE 

found  in  Japan,  haemorrhages  into  the  mucous  membrane, 
purulent  and  fibrinous  exudates  on  to  the  surface  of  the 
mucous  membrane  are  described  in  addition  to  ulceration. 

(3)  Tropical  or  Amoebic  Dysentery- — The  wall  of  the  bowel 
is  thickened,  due  largely  to  a  thickening  of  the  submucous 
coat,  partly  from  fibrous  change,  partly  from  inflammatory 
infiltration.  Scattered  through  the  mucous  membrane  are 
numerous  small  raised  nodules  the  size  of  pin  heads  or  small 
peas,  most  of  which  show  a  small  opening  in  the  mucous 
membrane  through  which  a  whitish  slough  can  be  seen  (Fig. 
67).  The  bowel  between  is  congested.  These  minute  ulcers 
tend  to  run  together,  forming  areas  of  more  extensive 
ulceration.  In  the  case  of  the  larger  ulcers  the  edges  are 
overhanging  and  the  floor  is  formed  of  submucous  or  muscular 
coat.  Rarely  perforation  of  the  bowel  may  occur. 

The  seat  of  the  more  intense  changes  varies  in  different 
cases.  Sometimes  it  is  the  caecum  and  ascending  colon, 
sometimes  the  transverse,  sometimes  the  descending  or 
pelvic  colon. 

The  condition  is  very  commonly  associated  with  the 
tropical  form  of  liver  abscess. 

Microscopic  Appearances.  —  The  wall  of  the  bowel  is 
thickened,  more  especially  the  submucous  coat.  It  is  also 
infiltrated  with  inflammatory  exudate  and  cells.  The  nodules 
above  mentioned  are  found  to  be  flask-shaped  ulcers  in  the 
submucous  coat,  with  overhanging  margins  and  a  small  opening 
into  the  lumen  of  the  bowel.  The  centre  is  occupied  with  a 
slough  consisting  of  necrotic  tissue  and  leucocytes.  Amoebae 
are  found  in  the  slough  and  in  the  submucous  coat  around. 
They  appear  as  large  rounded  cells  with  vacuolated  protoplasm 
and  a  relatively  small  round  nucleus.  They  can  be  seen  in 
specimens  stained  with  haematin  and  eosin,  but  are  better 
demonstrated  by  eosin,  methylene  blue  (p.  243).  In  the  areas 
of  more  extensive  ulceration  the  ulcers  lose  their  characteristic 
appearance,  and  the  changes  are  more  like  those  found  in  the 
other  type  of  dysentery. 


DISEASES  OF  THE  INTESTINE  '   169 

Mucous  Colitis. — This  is  a  condition  in  which  tubular 
casts  of  the  bowel  or  strings  and  masses  of  clear  mucus  are 
evacuated  from  time  to  time.  The  casts  consist  of  inspissated 
mucus  due  to  hypersecretion.  The  condition  is  frequently 
of  nervous  origin  aggravated  by  growth  of  bacteria  and  is 
accompanied  by  dilatation  of  the  large  intestine. 

Appendicitis. — The  appendix  is  a  cul  de  sac  in  continuity 
with  the  caecum  having  the  structure  of  the  large  intestine, 
and  being  subject  to  inflammatory  changes  spreading  from 
the  large  bowel,  as  well  as  to  such  changes  originating  in 
itself.  Foreign  bodies,  animal  parasites,  such  as  thread 
worms,  and  faecal  matter  may  lodge  in  its  lumen,  the  last, 
along  with  inspissated  secretion  from  its  own  glands,  forming 
the  so-called  concretions.  The  actual  cause  of  the  inflam- 
mation is  a  micro-organism,  usually  one  derived  from  the 
bowel,  e.g.  B.  coli,  streptococci)  B.  lactis  cerogenes,  B.  proteus, 
occasionally  B.  tuberculosis  and  streptothrix  actinomyces. 
Three  degrees  of  intensity  of  inflammatory  change  may  be 
recognised,  viz.  (i)  Catarrhal,  (2)  Ulcerative,  (3)  Gangrenous. 

1.  Catarrhal   Appendicitis. — Sometimes    there    is    little 
alteration  from  the  normal  to  be  observed  in  this  type.    As 
a  rule  the  organ  is  somewhat  swollen  and  congested. 

2.  Ulcerative  Appendicitis. — In  this  type  the  inflammatory 
change  is  more  intense.    In  addition  to  swelling  and  conges- 
tion there  is  destruction  of  the  mucous  membrane,  sometimes 
with  perforation. 

3.  Gangrenous  Appendicitis. — The  organ,  or  parts  of  it,  is 
of  a  deep  purple  colour.    There  is  exudate  on  the  peritoneal 
surface  and  ulceration  of  the  mucous  membrane,  sometimes 
with  abscess  formation  or  perforation  (Fig.  68). 

Peritonitis,  either  localised  or  general,  is  very  commonly 
associated  with  appendicitis.  When  limited  by  adhesions 
an  abscess  may  develop,  having  the  appendix  as  its  centre 
and  starting-point.  Occasionally  such  abscesses  burrow 


170  DISEASES  OF  THE  INTESTINE 

behind  the  caecum.  As  the  result  of  inflammation  the 
organ  may  become  obliterated  and  reduced  in  whole  or  part 
to  a  fibrous  cord.  Not  infrequently  adhesions  form  between 
the  appendix  and  neighbouring  parts,  such  as  uterus,  bowel, 
or  abdominal  wall ;  under  the  band  thus  formed,  portions 
of  bowel  sometimes  become  strangulated.  Phlebitis,  with 
resulting  thrombosis,  tends  to  occur  in  the  veins  of  the 
appendix  as  in  any  acute  inflammatory  condition  of  the 
bowel.  Organisms  may  cause  softening  of  the  thrombi,  and 
portions  of  these  may  be  carried  to  the  liver,  where  they  give 
rise  to  the  portal  pyaemia  type  of  liver  abscess. 

Microscopically r,  in  the  catarrh al  type  there  is  distension  of 
the  vessels  with  blood,  infiltration  of  the  coats  with  exudate, 
which  may  be  fibrinous,  also  with  leucocytes.  There  is,  in 
addition,  catarrh  of  the  mucous  membrane,  as  evidenced  by 
shedding  of  the  gland  cells. 

In  the  more  severe  types  of  the  disease  the  inflammatory 
changes  are  more  intense  ;  there  is  necrosis  of  the  mucous 
membrane  with  ulceration.  In  the  floor  of  the  ulcers  germs 
are  present  in  large  numbers.  There  is  also  more  or  less 
marked  peritonitis. 

Animal  Parasites. — The  important  animal  parasites 
which  may  be  met  with  in  the  intestines  are  : — Protozoa : 
Entamceba  histolytica  causing  the  tropical  form  of  dysentery, 
and  amoeba  coli  of  little  or  no  importance.  Worms  :  (i) 
Trematodes — Bilharzia  hcematobia  which  may  give  rise  to 
polypoid  outgrowths  of  the  mucous  membrane  of  the  rectum. 
(2)  Cestodes — Tcenia  solium,  the  cystic  stage  of  which  is  found 
in  the  pig.  Tcenia  mediocanellata  or  saginata,  the  cystic  stage 
of  which  occurs  in  the  ox.  Bothriocephalus  latus,  the  cystic 
stage  of  which  is  found  in  the  pike,  (3)  Nematodes — Ascaris 
lumbricoides ,  found  chiefly  in  the  upper  part  of  the  small 
intestine,  occasionally  in  the  bile  duct.  Oxynris  vermicularis , 
the  "  thread  "  or  "  seat  "  worm,  found  in  the  large  bowel  in 
children.  Ankylostoma  duodenale,  the  "  hook,"  "  tunnel/' 


DISEASES  OF  THE  INTESTINE  171 

or  "miner's"  worm,  found  attached  to  the  mucous  membrane 
of  the  jejunum.  This  worm  is  of  more  importance  than  the 
other  round  worms,  as  it  may  cause  a  severe  type  of  anaemia. 
Trichocephalus  dispar,  or  "  whip "  worm,  a  common  in- 
habitant of  the  caecum. 

Tumours. — Simple  tumours,  such  as  fibromata,  lipo- 
mata,  myomata,  and  cysts  of  various  kinds,  are  occasionally 
met  with.  Of  malignant  tumours,  sarcomata  are  rare. 

By  far  the  commonest  type  of  growth  in  the  bowel  is  the 
carcinoma.  Of  these,  all  types  may  be  met  with  :  squamous 
epitheliomata  in  the  rectum,  the  various  types  of  adeno- 
carcinomata,  as  columnar -cell  carcinoma,  colloid  cancer, 
scirrhous  cancer.  The  growth  is  usually  small.  It  may  be 
a  mere  ring  of  infiltration  round  the  wall  of  the  gut,  produc- 
ing a  constriction  when  looked  at  from  the  outside,  with 
narrowing  of  the  lumen.  In  other  cases  it  forms  a  fungating 
growth  projecting  into  the  interior  (Fig.  69).  Ulceration  of 
the  bowels  is  very  commonly  associated,  and  perforation 
may  occur.  There  are  often  adhesions  with  neighbouring 
structures,  and  the  nearest  lymphatic  glands  are  usually 
enlarged  and  infiltrated.  Secondary  growths  in  the  liver  are 
very  commonly  present.  Diffusion  of  the  growth  throughout 
the  peritoneal  cavity  is  sometimes  seen. 

As  regards  site,  carcinomata  may  occur  at  any  part  of  the 
small  or  large  intestine.  They  are,  however,  much  more 
common  in  the  latter,  occurring  more  especially  at  points  of 
narrowing  of  the  gut,  such  as  the  ileo-caecal  valve  and  the 
ascending  colon  immediately  above  the  caecum;  at  points 
where  the  intestine  changes  its  direction,  as,  for  example,  at 
the  hepatic,  splenic,  and  sigmoid  flexures.  A  large  proportion 
of  cases  show  the  growth  in  the  lower  bowel,  usually  2  to 
3  inches  from  the  anal  orifice. 

The  appendix  is  occasionally  the  seat  of  a  malignant 
growth  of  the  adeno-carcinoma  type.  This  growth  seems 


172  DISEASES  OF  THE  PERITONEUM 

to  arise  in  appendices  which  have  been  previously  inflamed 
and  are  partially  obliterated.  Such  tumours  show  little 
tendency  to  spread,  being  apparently  of  low  malignancy. 


DISEASES  OF  THE  PERITONEUM 

Haemorrhage. — Small  petechial  haemorrhages  occur  into 
the  subperitoneal  tissue  in  infective  conditions  and  in  severe 
anaemias.  Free  blood  and  blood -clots  in  the  peritoneal 
cavity  may  be  due  to  rupture  of  an  organ  (liver  or  spleen) 
from  injury,  acute  peritonitis,  rupture  of  a  vascular  tumour, 
as,  for  example,  in  the  spleen,  or  rupture  of  an  aneurysm. 

Dropsy  of  the  Peritoneal  Cavity  or  Ascites. — This 
condition  may  be  found  in  diseases  which  tend  to  produce 
dropsy  elsewhere,  such  as  chronic  heart  and  renal  disease, 
or  it  may  be  due  to  cirrhosis  of  the  liver.  In  long-standing 
cases  the  peritoneum  is  frequently  opaque  and  thickened. 
The  fluid  is  usually  clear ;  when  it  is  milky  the  turbidity  is 
usually  caused  by  the  presence  of  protein  bodies  of  the  nature 
of  globulins.  Very  rarely  milkiness  is  due  to  the  presence  of 
fat  globules  (chylous  ascites)  escaped  from  an  injured  lacteal 
vessel  (e.g.  in  filariasis). 

Acute  Peritonitis. — This  may  be  due  to  (i)  spread  of 
inflammation  from  structures  within  the  abdomen,  such  as 
the  appendix  and  Fallopian  tubes  or  from  the  pleura ;  (2) 
rupture  of  the  gut  from  injury  or  perforation  associated  with 
ulceration ;  (3)  blood  or  lymph  infection.  It  may  be  general- 
ised throughout  the  peritoneal  cavity  or  localised  by  adhesions. 

Naked-eye  Appearances. — There  is  more  or  less  free  fluid 
in  the  cavity,  more  especially  in  the  pelvis  and  in  dependent 
parts.  The  fluid  may  be  yellow  or  brownish  and  contains 
flakes  of  lymph.  It  is  often  mixed  with  faecal  matter  or 
stomach  contents,  and  usually  has  a  foul  smell.  The  omentum 
is  swollen  and  its  vessels  injected.  There  is  fibrinous  exudate 


DISEASES  OF  THE  PERITONEUM  173 

on  the  surface  of  the  bowel,  more  especially  between  the  coils 
of  the  intestine  (Fig.  68).  The  coils  are  thus  glued  together. 
Not  infrequently  on  separating  the  coils  small  abscesses  are 
opened  into. 

Microscopic  Appearances  of  the  Omentum  in  Cases  of 
Peritonitis. — There  is  distension  of  the  vessels,  exudation 
of  fibrin  on  the  surface  and  in  the  substance,  swelling  and 
throwing-off  of  the  endothelial  cells.  These  are  found  amongst 
the  fibrin  threads  as  large,  swollen,  and  vacuolated  cells,  often 
containing  germs  and  polymorphonuclear  leucocytes.  Numer- 
ous polymorphs  are  found  in  the  fibrin  on  the  surface  and 
infiltrating  the  tissue  generally.  There  is  swelling  of  the 
collections  of  lymphoid  tissue  along  the  vessels,  and  many 
free  lymphocytes  are  found  in  the  exudate. 

Film  preparations  of  the  exudate  show  numerous  poly- 
morphonuclear leucocytes  in  various  stages  of  degeneration, 
large  mononuclear  cells  often  vacuolated  and  frequently  con- 
taining leucocytes  which  they  have  ingested,  lymphocytes,  and 
micro-organisms. 

Chronic  Peritonitis. — Large  or  smaller  areas  of  thicken- 
ing of  the  peritoneum,  or  rather  of  the  subendothelial  fibrous 
tissue  of  the  peritoneum,  are  found  frequently,  more  especially 
over  liver  and  spleen.  They  may  be  associated  with  adhesions, 
and  are  specially  frequent  in  syphilis.  A  more  general 
thickening  of  the  peritoneum  is  found  in  cases  of  long-standing 
ascites. 

Tuberculous  Peritonitis.  —  This  may  be  associated  with 
tuberculous  ulceration  of  the  bowel,  but  not  infrequently 
no  such  lesion  of  the  bowel  can  be  found.  Usually,  however, 
the  mesenteric  glands  are  the  seat  of  tuberculosis.  The 
condition  may  also  occur  as  a  part  of  a  generalised  blood 
infection. 

Naked-eye  Appearances. — The  coils  of  the  intestine  are 
commonly  adherent  more  or  less  firmly  to  one  another.  On 
separating  the  coils,  if  this  be  possible,  there  will  be  found 
covering  the  surface  of  the  bowel  and  mesentery,  also  the 


174  DISEASES  OF  THE  PERITONEUM 

surface  of  liver  and  spleen,  as  well  as  the  parietal  peritoneum, 
numerous  small  opaque  white  or  yellow  areas,  the  size  of  a 
pin  head  or  larger  (Fig.  70).  Often  the  coils  of  bowel  are  too 
firmly  adherent  to  one  another  to  be  separated  without 
tearing.  The  great  omentum  is  thickened,  drawn  up  and 
infiltrated  with  grey  tubercles.  Occasionally  free  fluid  may 
be  present.  The  matting  of  the  intestines  leads  to  interfer- 
ence with  peristalsis.  Adhesions  may  lead  to  the  formation 
of  bands  under  which  loops  of  bowel  may  subsequently 
become  strangulated.  Occasionally  rupture  of  the  bowel 
may  occur  as  the  result  of  erosion  of  the  wall  from  the 
peritoneal  aspect. 

Microscopically,  the  appearances  are  those  characteristic  of 
tubercle.  Giant  cells  are  often  specially  numerous  and  well 
developed. 

Tumours. — Growths  primary  in  the  peritoneum  are  rare. 
Endotheliomata  are  met  with  occasionally  growing  in  the  form 
of  multiple  polypoid  masses.  Dissemination  of  carcinoma 
sometimes  occurs  secondary  to  rupture  of  a  cystic  growth 
of  the  ovary  or  the  invasion  of  a  bowel  tumour  into  the 
peritoneal  cavity. 


CHAPTER  IX 

DISEASES   OF  THE  LIVER,  BILE  PASSAGES,   AND   PANCREAS 

DISEASES  OF  THE  LIVER 

Deformities. — A  transverse  sulcus  across  the  lower  por- 
tion of  the  right  lobe  of  the  organ  is  frequently  seen,  due 
to  the  wearing  of  tight  corsets.  Perpendicular  sulci  are  also 
met  with,  due  to  folding  of  the  liver  from  a  similar  cause. 

ALTERATIONS  IN  THE  CIRCULATION 

1.  Anaemia.  —  Yellow  or  white  patches   are   frequently 
seen  on  the  surface  of  the  organ.    They  are  due  to  localised 
ansemia  from  pressure. 

2.  Chronic  Venous  Congestion. — This  condition  is  found 
in  cases  of  chronic  valvular  disease  of  the  heart  and  in  chronic 
pulmonary   lesions.    The   organ   is   enlarged   in   the   early 
stages.    In  the  later  stages  it  may  be  smaller  than  normal. 
It  has  a  dark  purple  colour  with  paler  areas  (Frontispiece, 
Fig.  5),  and  is  firmer  than  usual.    On  section,  the  cut  surface 
shows  a  mottled  appearance,  likened  to  nutmeg.    There  are 
areas  of  congestion,  dark  purple  in  colour,  and  areas  of  fatty 
change,  pale  yellow.    The  branches  of  the  hepatic  vein  are 
dilated. 

Microscopic  Appearances. — In  the  very  earliest  stage  there 
may  be  little  more  than  the  deposit  of  yellow  pigment  in  a 

175 


176  DISEASES  OF  THE  LIVER 

zone  of  liver  cells  round  the  central  vein.  In  the  later  stages 
there  is  dilatation  of  the  central  veins  and  the  capillaries 
draining  into  them,  with  compression  and  atrophy  of  the 
columns  of  liver  cells  between.  The  liver  cells,  more  par- 
ticularly those  at  the  margin,  may  show  fatty  infiltration.  There 
is  some  increase  of  the  fibrous  tissue  of  the  organ  in  the  more 
advanced  cases. 

3.  Embolism  and  Thrombosis  in  the  Portal  Vein. — 

Thrombosis  of  the  portal  vein  is  sometimes  found  in  connection 
with  cirrhosis  of  the  liver  and  malignant  disease.  It  may 
also  occur  as  the  result  of  inflammation  round  a  perforating 
ulcer  of  the  stomach. 

Portions  of  thrombi  from  rootlets  of  the  portal  vein  in 
the  neighbourhood  of  inflammatory  foci,  e.g.  the  appendix, 
are  caught  in  the  branches  of  that  vein  within  the  liver. 
Secondary  thrombosis  occurs  in  connection  with  such  emboli, 
the  condition  sometimes  spreading  to  large  branches  of  the 
vein.  As  the  emboli  contain  organisms,  abscess  formation 
is  set  up. 

As  regards  the  effect  upon  the  liver  of  blocking  of  a  branch 
of  the  portal  vein,  this  may  be  very  slight,  owing  to  the  fact 
that  the  liver  lobule  is  also  supplied  with  blood  from  the 
hepatic  artery.  Sometimes  the  area  supplied  assumes  a 
darker  brown,  even  a  red  colour,  but  on  microscopic  examina- 
tion little  is  seen  in  such  an  area  beyond  dilatation  of  the 
capillaries.  The  liver  cells  commonly  show  no  evidence  of 
necrosis.  Occasionally,  however,  in  such  an  area  a  partial 
necrosis  of  the  inner  two-thirds  of  the  lobule  may  be  seen. 


DEGENERATIVE  CHANGES 

i.  Cloudy  Swelling. — This  is  found  in  varying  degrees  in 
all  infective  conditions,  and  occasionally  apart  from  infections, 
as  in  haemorrhage  of  the  pons  where  there  was  a  markedly 
raised  temperature  during  life. 


DISEASES  OF  THE  LIVER  177 

The  organ  is  slightly  enlarged  and  has  a  pale  appearance. 
It  is  soft  and  friable.  The  last  point  is  tested  by  the  ease 
with  which  the  finger  may  be  pushed  into  the  substance  of 
the  organ.  On  section,  the  cut  surface  has  a  hazy,  misty 
appearance,  described  as  like  the  effect  of  plunging  a  portion 
of  normal  liver  into  boiling  water.  The  outline  of  the  liver 
lobules  is  no  longer  visible.  The  condition  may  be  associated 
with  congestion  of  some  of  the  vessels  of  the  organ.  It  is 
also  commonly  combined  with  a  degree  of  fatty  change. 

Microscopic  Appearances. — The  liver  cells  are  swollen  and 
granular.  In  the  fresh  condition  the  nuclei  are  obscured  by 
the  granules,  but  these  are  readily  dissolved  with  dilute  acetic 
acid,  when  the  nucleus  is  rendered  visible  again.  The  cells 
often  show  a  tendency  to  separate  from  one  another  owing  to 
solution  of  their  cement  substance.  There  may  be  some 
infiltration  of  the  portal  spaces  with  inflammatory  cells. 

The  condition  is  usually  complicated  with  some  fatty  change 
in  the  liver  cells.  The  nucleus  in  the  earlier  stages  stains 
more  intensely  ;  in  the  later  stages  it  tends  to  lose  its 
characteristic  staining  reaction  with  basic  dyes. 

2.  Fatty  Change. — Two  types  of  this  condition  are 
commonly  distinguished  : — 

(a)  Fatty  degeneration,  by  which  is  usually  meant  the 
breaking  down  of  the  chemical  constituents,  more  especially 
the  combinations  of  proteins  with  fatty  compounds,  under 
the  action  of  some  poison,  chemical  or  bacterial. 

The  organ  may  not  be  much  altered  in  size  or  it  may 
be  smaller  than  normal.  It  is  paler  than  usual,  of  a  bright 
yellow  colour,  soft,  and  friable.  On  section,  the  parts 
showing  more  advanced  fatty  change  are  seen  as  opaque 
yellow  areas.  These  may  be  in  the  centre  of  the  lobules, 
or  they  may  form  a  zone  at  the  periphery,  or  the  change 
may  be  present  throughout. 

Microscopic  Appearances.  —  Sections  should  be  stained 
with  Sudan  III.,  Scharlach  R,  or  Nile  blue  sulphate.  As 


178  DISEASES  OF  THE  LIVER 

already  stated,  the  change  may  be  at  the  periphery  of  the 
lobule,  in  the  centre  or  throughout.  It  is  usually  described 
as  occurring  most  characteristically  at  the  centre.  The 
globules  of  fat  in  the  cells  tend  to  be  numerous  and  small. 
The  nucleus  may  show  degenerative  changes  :  either  increased 
intensity  of  staining  in  the  early  stages,  or  loss  of  staining 
reaction  in  the  more  advanced  condition. 

(b)  Fatty  infiltration  may  be  defined  as  the  absorption  in 
excess  of  fatty  material  and  the  deposition  of  it  in  a  demon- 
strable form  in  the  protoplasm  of  the  liver  cell.  A  rigid 
distinction  between  this  and  the  preceding  type  cannot, 
however,  be  made.  The  two  conditions  pass  into  one 
another  and  are  frequently  combined.  Thus  there  is  reason 
to  believe  that  in  the  fatty  degeneration  of  phosphorus 
poisoning  the  fat  in  the  liver  cell  is  largely  derived  from  out- 
side. Hence  in  very  many  cases  it  is  safer  to  use  the  term 
fatty  change.  It  is  convenient,  however,  in  certain  cases  to 
make  a  distinction  into  two  types,  the  extremes  of  which  are 
readily  separated  from  one  another. 

The  organ  tends  to  be  larger  than  normal,  in  some 
cases  very  markedly  so.  It  is  pale  yellow  in  colour 
(Frontispiece,  Fig.  2).  Its  consistence  varies  in  different 
cases.  It  may  be  softer  and  more  friable,  or  it  may  be  (in 
cases  where  there  is  cirrhosis  combined)  firmer.  On  section, 
the  change  may  appear  most  marked  in  the  periphery  of 
the  lobule,  or  it  may  be  diffuse. 

Microscopic  Appearances. — The  globules  of  fat  within  the 
liver  cells  tend  to  be  large,  pressing  aside  the  protoplasm  and 
nucleus  of  the  liver  cell.  The  change  may  be  at  the  periphery 
of  the  lobule,  i.e.  merely  an  exaggeration  of  a  change  found 
normally  in  the  liver  during  digestion,  or  it  may  be  diffuse. 
It  is  frequently  combined  with  increase  of  fibrous  tissue  in  the 
organ. 

3.  Focal  Necrosis. —  Areas  of  focal  necrosis  are  found 
in  the  liver  in  typhoid  j 'ever  and  in  eclampsia.  They  appear 


DISEASES  OF  THE  LIVER  179 

as  opaque  white  or  yellow  points  scattered  through  the  liver 
substance,  but  often  they  are  too  minute  to  be  seen  with 
the  unaided  eye.  Cloudy  swelling  is  always  associated. 

In  eclampsia  the  liver  shows  three  characteristic  changes, 
which  may  not,  however,  all  be  present  in  a  given  case 
(see  p.  271). 

(1)  Hemorrhage  under  the  capsule,  which  may  be  very 
extensive ;  also  haemorrhage  into  the  substance  of  the  organ. 

(2)  Fatty  change,  usually  most  marked  at  the  margin  of 
the  necrotic  areas. 

(3)  Areas  of  focal  necrosis,  usually  situated  at  the  periphery 
of  the  lobules,  and  often  too  small  to  be  seen  with  the  naked 
eye. 

4.  Amyloid  (Waxy)  Degeneration.  —  For  causation  of 
waxy  change  see  p.  105. 

The  organ  is  commonly  enlarged,  often  very  much  so. 
It  is  anaemic  and  has  a  translucent  appearance  if  the  condition 
be  advanced.  It  is  firm  and  elastic  in  consistence  like  india- 
rubber.  On  section,  the  cut  edge  remains  sharp.  The  cut 
surface  has  the  same  translucent  appearance.  The  condition 
is  often  combined  with  some  degree  of  fatty  change.  When 
the  cut  surface  is  treated  with  a  solution  of  iodine,  the 
waxy  areas  take  on  a  mahogany  brown  colour  (Frontispiece, 
Fig.  4). 

Microscopic  Appearances. — The  waxy  material  has  a  clear 
translucent  appearance  in  unstained  specimens.  In  prepara- 
tions treated  with  methyl  violet  it  shows  a  rose-pink  to  purple 
colour. 

In  the  early  stages  the  change  is  limited  to  the  middle 
coats  of  the  branches  of  the  hepatic  arteries  and  portal  veins 
in  the  portal  tracts.  It  is  the  bands  of  connective  tissue 
between  the  muscle  fibres  which  show  the  change.  Later  on, 
the  peri-endothelial  connective  tissue  of  the  capillaries  in  the 
middle  zone  of  the  lobules  is  affected.  Still  later,  the  change 
becomes  diffuse.  The  capillaries  and  also  the  liver  cells 
become  compressed  by  the  swollen  amyloid  material,  and 


i8o  DISEASES  OF  THE  LIVER 

occasionally  little  or  nothing  is  seen  in  certain  areas  but  masses 
of  waxy  tissue. 

5.  Pigmentary  Changes. — A  black  coloration  of  those 
portions  of  the  organ  nearest  the  intestines  is  often  seen, 
due  to  the  action  of  the  H2S  from  the  gut  upon  the  iron  pig- 
ment of  the  organ.  This  is,  of  course,  a  post-mortem  change. 
Increase  in  the  amount  of  iron-containing  pigment  in  the  liver 
is  found  in  cases  where  there  is  an  increase  in  the  destruction 
of  the  red  blood  corpuscles  within  the  liver,  as  in  septicaemias 
and  severe  anaemias,  notably  in  pernicious  anaemia.  This 
increase  of  hsemosiderin  pigment  gives  a  yellow-brown  colour 
to  the  organ.  The  pigment  may  be  brought  out  in  a  striking 
fashion  by  pouring  some  ferrocyanide  of  potassium  (2  per  cent) 
over  the  cut  surface  of  the  organ,  and  then  some  dilute  HC1 
(i  per  cent),  repeating  the  process  once  or  twice  until  the 
Prussian  blue  colour  appears  (Frontispiece,  Fig.  i).  Micro- 
scopic sections  of  the  organ  should  be  treated  in  a  similar 
way.  In  chronic  venous  congestion,  also  in  malaria,  there  is 
a  deposition  of  pigment  in  the  liver  cells.  In  cases  where 
there  is  obstruction  to  the  outflow  of  the  bile  there  is  a  yellow 
coloration  of  the  organ,  which  becomes  green  on  exposure  to 
the  oxygen  of  the  air  (Frontispiece,  Fig.  3). 

ACUTE  INFLAMMATIONS  OF  THE  LIVER 

1.  Acute  Perihepatitis  is  found  as  a  part  of  a  general 
peritonitis.    The  surface  of  the  liver  is  covered  with  more 
or  less  fibrinous  exudate. 

2.  Acute  Hepatitis. — Acute  inflammation  of   the    liver 
substance  is  found  in  slight  degree  in  all  infective  fevers.     It 
is  always  combined  with  cloudy  swelling,  and  may  be  associated 
with  focal  necrosis,  as  in  typhoid  fever.    The  evidences  of 
inflammation  are  usually  slight,  being  confined  to  infiltration 
of  the  portal  tracts  with  inflammatory  cells. 


DISEASES  OF  THE  LIVER  181 

3.  Suppurative  Hepatitis.— In  discussing  the  types  of 
liver  abscess  the  paths  by  which  organisms  may  reach  the 
liver  should  be  called  to  mind.  There  are  three,  (a)  the 
hepatic  artery,  (b)  the  portal  vein  draining  the  whole  of  the 
abdominal  contents,  (c)  the  excretory  duct  of  the  organ — 
the  bile  duct.  Thus  at  once  we  may  distinguish  three  types 
of  abscess  or  suppurative  hepatitis. 

There  are,  in  addition,  three  other  types  to  v/hich  special 
names  are  given. 

Types  of  Liver  Abscess. 

1.  Pyaemic. 

2.  Portal  pyaemic. 

3.  Biliary. 

4.  Actinomycotic. 

5.  Tropical. 

6.  Suppurating  hydatid  cyst. 

(1)  Suppurative    Hepatitis   of  Arterial   Origin  —  Pycemic 
Abscess. — This  type  is  found  in  cases  of  pyaemia,  septicaemia, 
and    ulcerative    endocarditis,    where    there    are    organisms 
circulating  in  the  blood  of  the  body  generally.    The  abscesses 
in  this  case  are  minute  and  usually  numerous.    They  are 
scarcely  visible  to  the  naked  eye,  and  there   are   similar 
abscesses  in  other  organs. 

(2)  Suppurative  Hepatitis  of  Portal  Origin — Portal  Pycemic 
Abscess. — In  this  type  the  infective  agent  comes  to  the  liver 
by  way  of  the  portal  vein.     It  is  usually  a  germ-laden  thrombus 
from  a  thrombosed  vein  in  the  neighbourhood  of  an  inflam- 
matory focus,  such  as  an  appendicitis.    The  abscesses  in 
this  case  are  usually  about  the  size  of  a  pea.    They  occur  in 
groups  or  clusters  like  bunches  of  grapes  (Fig.  71).    They 
form  cavities  containing  yellow  or  greenish  pus,  their  walls 
being  formed  of  necrosed  liver  tissue.    Septic  thrombi  can 
usually  be  found  in  branches  of  the  portal  vein  (Fig.  7 1).    The 
condition  is  sometimes  known  as  portal  pyaemia. 

(3)  Sitppurative   Hepatitis  of  Bile -Duct  Origin — Biliary 


i82  DISEASES  OF  THE  LIVER 

Abscess. — This  is  associated  with  suppurative  cholangitis 
(suppurative  inflammation  of  the  bile  ducts),  which  is  commonly 
caused  by  obstruction  to  the  bile  passages  from  the  presence 
of  gall  stones  or  a  tumour.  The  abscesses  are  numerous, 
usually  minute  and  scattered  uniformly  throughout  the 
organ.  The  liver  is  bile  stained.  Cirrhosis  of  the  liver  is 
not  infrequently  present  in  addition. 

(4)  Actinomycotic  Abscess. — This  type  is  usually  a  special 
variety  of  the  portal  pysemic  abscess.      It  is  associated  with 
a  focus  of  infection  with  the  Streptothrix  actinomyces  in  some 
part  of  the  intestinal  tract,  e.g.  the  vermiform  appendix. 
The  affected  portion  of  liver  has  a  worm-eaten  appearance 
owing  to  the  presence  of  numerous  small  cavities  containing 
pus,  with  areas  of  necrotic  liver  around,  in  which  there  is 
some  fibrosis. 

(5)  Tropical  Abscess. — This  is  usually  single  and   fairly 
large  (Fig.  72).    The  process  is  more  a  necrosis  of  the  liver 
substance    than    a    true    suppurative    inflammation.    The 
contents  of  the  abscess  have  a  pink  colour  and  creamy 
consistence.     The   condition  is  commonly  associated  with 
tropical  dysentery.     The  Entamceba  histolytica  is  found  in 
large  numbers  in  the  tissue  in  the  margin  of  the  abscesses, 
and  usually  in  the  pus  also. 

(6)  Suppuration  in  a  Hydatid  Cyst. — In  this  case  also  the 
abscess  cavity  is  large  and  may  be  solitary.     Mixed  with  the 
pus  there  will  be  the  ectocyst  of  the  parasite.    The  cavity 
is  usually  limited  by  fibrous  tissue. 


ACUTE  AND  SUBACUTE  LIVER  ATROPHY 

This  is  a  condition  which  is  associated  clinically  with 
jaundice,  vomiting,  a  diminishing  liver  dulness,  and  eventu- 
ally coma.  It  is  often  connected  more  or  less  closely  with 
such  diseases  as  syphilis,  tuberculosis,  and  influenza,  and  a 
number  of  cases  have  developed  in  women  during  the  later 


DISEASES  OF  THE  LIVER  183 

months  of  pregnancy.  There  is  a  general  consensus  of  opinion 
that  the  condition  is  a  toxic  one,  but  what  the  nature  of  the 
toxin  is  and  where  it  originates  has  not  yet  been  determined. 
It  has  been  suggested  that  it  has  its  seat  in  the  intestine, 
and  very  commonly  one  finds  in  these  cases  evidence  of  acute 
inflammation  of  the  duodenum  and  upper  bowel,  but  this 
condition  has  also  been  ascribed  to  the  action  of  toxic  bile 
from  the  necrosed  liver. 

Two  stages  in  the  disease  may  be  recognised,  and,  as  a 
result,  two  types  of  cases  are  met  with  post  mortem. 

(1)  Acute  cases  in  which  death  occurs  within  one  or  two 
weeks  of  the  onset  of  the  symptoms,  and  in  which  degenerative 
changes  predominate  in  the  liver.    There  is  usually  little 
evidence  of  overgrowth  of  fibrous  tissue.    To  this  type  the 
name  "  acute  yellow  atrophy  "  or  "  acute  liver  atrophy  "  is 
more  particularly  applicable. 

(2)  Subacute  cases,  lasting  some  weeks,  or  even  months, 
in  which  there  is  more  or  less  evidence  of  the  reformation  of 
functioning  liver   tissue    with  overgrowth  of  fibrous  tissue. 
For  such  cases  the  terms  "  subacute  yellow  atrophy,"  "  sub- 
acute  liver  atrophy,"  and  for  the  cases  with  marked  regenera- 
tion "  multiple  nodular  hyperplasia,"  have  been  suggested. 

(i)  Acute  Atrophy — Naked-eye  Appearances. — The  liver 
is  reduced  in  size,  often  markedly  so.  Its  capsule  tends  to 
be  shrivelled.  The  organ  shows,  as  a  rule,  areas  of  different 
colours,  yellow  and  red.  In  the  more  acute  types  the  yellow 
areas  predominate. 

Microscopic  Appearances. — In  the  yellow  areas  the  liver 
cells  are  usually  visible,  but  they  show  marked  evidence  of 
degenerative  changes.  They  are  swollen,  granular,  frequently 
contain  fatty  globules,  and  their  nuclei  have  to  a  great  extent 
lost  their  staining  reaction.  In  addition,  there  is  usually  more 
or  less  overgrowth  of  fibrous  tissue  extending  from  the  portal 
tracts.  This  fibrous  tissue  is  vascular  and  cellular.  In  the 
neighbourhood  of  the  portal  tracts  are  small  vermiform  strings 
of  cells  whose  nuclei  stain  deeply.  Sometimes  these  have  an 


184  DISEASES  OF  THE  LIVER 

obvious  lumen.  They  represent  the  remains  of  pre-existing 
and  of  proliferating  small  bile  ducts.  In  process  of  degener- 
ating the  liver  cell  undergoes  coagulation  of  its  substance, 
followed  by  disappearance  first  of  the  carbohydrate  and  fatty 
elements,  second  of  the  albuminous  constituents. 

In  the  red  areas  little  that  is  characteristic  of  liver  structure 
remains.  The  tissue  is  a  vascular  connective  tissue  with 
dilated  capillaries,  and  shows  large  numbers  of  endothelial 
cells  which  may  contain  pigment,  a  loose  connective-tissue 
stroma,  occasional  degenerated  liver  cells  scarcely  recognisable 
as  such,  and  a  few  leucocytes.  In  the  neighbourhood  of  the 
portal  tracts  the  small  bile  ducts  are  numerous,  and  may  show 
evidence  of  proliferation  of  their  cells  (mitotic  figures). 

(2)  Subacute  Atrophy  —  Naked-eye  Appearances. —  The 
organ  is  of  a  brownish-red  colour,  with  yellow  or  greenish 
nodules  varying  much  in  size,  sometimes  projecting  beyond  the 
general  surface  (Fig.  73).  On  section,  these  yellow  nodules 
may  be  isolated,  or  may  be  found  scattered  through  the  sub- 
stance of  the  liver.  Where  the  nodules  are  numerous  the 
organ  presents  the  appearance  of  a  coarse  cirrhosis,  from 
which  condition  it  is  often  very  difficult  to  distinguish  it. 

Microscopic  Appearances. — The  red-bfown  portion  of  the 
organ  consists  of  a  fairly  vascular  connective  tissue  with  groups 
of  small  bile  ducts,  scattered  endothelial  cells,  and,  as  a  rule, 
with  no  liver  tissue  to  be  found.  The  yellow  nodules  present 
the  appearance  of  liver  tissue.  They  are  composed  of  masses 
of  liver  cells,  sometimes  arranged  in  columns,  at  other  times 
closely  packed  together.  Lobular  arrangement  is  imperfect. 
Many  of  the  cells  are  large  and  multinucleated ;  some  may  be 
found  showing  mitotic  division  of  their  nuclei.  The  appear- 
ances at  the  margin  of  these  nodules  suggest  that  they  are 
enlarging  and  pressing  aside  the  surrounding  tissue.  The 
fibrous  tissue,  being  newly  formed,  contains  few  elastic  fibres. 

It  will  thus  be  seen  that  the  disease  is  essentially  a 
degeneration  of  the  liver  parenchyma  under  the  action  of 
some  poison.  Complementary  to  this,  there  is  an  overgrowth 
of  fibrous  tissue  starting  from  the  portal  tracts. 


DISEASES  OF  THE  LIVER  185 

The  condition  may  thus  be  regarded  as  an  acute  cirrhosis. 
It  forms  a  connecting  link  between  the  purely  degenerative 
changes,  such  as  occur  in  phosphorus  poisoning,  and  the 
chronic  interstitial  inflammations  or  cirrhoses. 

Following  the  degenerative  changes,  attempts,  more  or 
less  successful,  are  made  to  regenerate  liver  tissue  in  two 
ways  :  (i)  By  proliferation  of  the  bile  ducts.  This,  although 
it  is  an  imitation  of  the  way  in  which  the  liver  lobules  are 
produced  in  embryonic  life,  seldom  results  in  the  formation 
of  liver  parenchyma.  (2)  By  proliferation  of  liver  cells  which 
survive  the  destructive  influence  of  the  poison,  with  resulting 
formation  of  nodules  of  glandular  cells  more  or  less  resembling 
in  structure  liver  lobules,  and  probably  functioning  as  such* 

CHRONIC  INFLAMMATION  OF  THE  LIVER 

Types. 

1.  Cirrhosis. 

(a)  Common. 

(b)  Biliary. 

(c)  Syphilitic. 

2.  Syphilis. 

3.  Tuberculosis. 

Cirrhosis 

The  term  "  cirrhosis,"  introduced  by  Laennec,  simply 
means  "  yellow."  It  has,  however,  come  to  be  synonymous 
with  fibrosis,  and  is  applied  to  all  conditions  of  the  liver 
in  which  there  is  abnormal  development  of  connective 
tissue. 

The  condition  is  caused  by  any  slowly  acting  poison  or 
irritant.  Thus  chronic  intoxications,  such  as  alcohol  or  lead, 
produce  it.  Infective  conditions,  such  as  syphilis,  may  also 
cause  it.  Retention  of  the  bile  from  obstruction  to  the  bile 
ducts  will  produce  it ;  also  inflammatory  conditions  of  the 
small  bile  ducts,  which  so  commonly  accompany  obstruction. 


186  DISEASES  OF  THE  LIVER 

Lastly,  abnormal  accumulation  of  pigment,  as  in  malaria  and 
chronic  venous  congestion,  is  a  factor. 

The  liver  consists  of  two  types  of  cellular  elements :  (i) 
highly  differentiated  and  functioning  gland  cells  very  sus- 
ceptible to  the  action  of  poisons,  and  capable  of  little  in  the  way 
of  reaction ;  (2)  cells  less  highly  differentiated— connective  - 
tissue  cells — not  so  readily  damaged  by  the  action  of  poisons, 
and  capable  of  reaction  and  proliferation  in  circumstances 
where  the  liver  cells  degenerate.  The  mere  disappearance 
of  the  glandular  cells  is  followed  by  a  complementary  pro- 
liferation of  connective  tissue.  This  is  well  seen  in  the  less 
acute  types  of  liver  atrophy.  But  where  there  is  an  irritant 
constantly  present,  as  in  syphilis,  alcoholism,  retention  of 
bile,  and  inflammation  of  the  small  bile  ducts,  another  factor 
comes  into  play,  namely,  the  proliferative  reaction  of  the 
connective-tissue  cell  under  irritation.  These  two  factors 
are,  no  doubt,  both  operative  in  the  production  of  cirrhosis 
of  the  liver. 

Where  there  is  any  great  amount  of  destruction  of  hepatic 
gland  cells  the  stimulus  to  regenerate  is  felt  by  the  organ, 
and  is  answered  by  the  formation  of  new  areas  of  liver  tissue. 
This  is  a  prominent  feature  in  subacute  liver  atrophy,  and 
evidence  of  it  is  usually  present  in  cirrhosis  also. 

Classification. — The  terms  monolobular  (where  the  areas 
of  liver  cut  off  by  bands  of  fibrous  tissue  represent  single 
lobules)  and  polylobular  (where  such  areas  represent  groups 
of  lobules)  are  often  used  to  characterise  types  of  cirrhosis. 
They  are  practically  the  same  as  fine  and  coarse  cirrhosis 
respectively.  They  are  not  very  useful  as  a  basis  of  classifica- 
tion, owing  to  the  fact  that  the  two  conditions  are  usually 
to  be  seen  alongside  one  another  in  the  same  liver.  Another 
couple  of  terms  used  sometimes  are  "  hypertrophic  "  (meaning 
an  abnormally  large  liver)  and"atrophic"  (abnormally  small). 
Owing  to  the  fact  that  in  many  instances  it  is  impossible  to 
decide  whether  a  liver  is  enlarged  or  not,  these  terms  are 


DISEASES  OF  THE  LIVER  187 

rather  to  be  avoided.    The  method  of  classification  adopted 
is  as  follows  : — 

A,  Common  Cirrhosis. — The  ordinary  type  found  in  asso- 
ciation with  chronic  intoxications,  distinguishing  (a)  an  early 
stage  where  the  liver  is  large,  and  (b)  a  late  stage  where  it  is 
small.  This  variety  is  usually  polylobular. 

1.  Early  Stage. — The  liver  is  enlarged  and  has  a  somewhat 
rough  surface.    In  some  cases  it  is  red,  from  congestion  ;   in 
other  cases  it  is  yellow,  from  fatty  change. 

The  organ  is  firmer  and  tougher  than  normal,  and  on 
section  shows  bands  of  vascular  fibrous  tissue  running  through 
it.  These,  as  a  rule,  are  not  very  obvious. 

Microscopic  Appearances. — Bands  of  vascular  and  cellular 
connective  tissue  divide  up  the  liver  into  areas,  at  one  time 
representing  a  single  lobule,  at  another  time  a  group  of  lobules. 
The  liver  cells  may  show  little  change,  or  there  may  be  more 
or  less  fatty  infiltration. 

2.  Advanced,  Stage. — This  is  the  more  common  type  of 
the  disease,  known  as  "  hobnail,"  "  drunkard's,"  or  "  gin- 
drinker's  "  liver. 

The  liver  is  distinctly  reduced  in  size.  It  has  a  roughened 
surfacet  owing  to  the  presence  of  nodules  varying  much  in 
size.  It  usually  has  a  pale  yellow  colour.  The  capsule 
may  be  thickened.  It  is  distinctly  tougher  and  firmer  than 
normal.  On  section,  it  shows  bands  of  grey  fibrous  tissue 
passing  through  the  organ  in  all  directions,  dividing  it  up 
into  rounded  areas  varying  much  in  size  (Fig.  74).  A  number 
of  cases  are  recorded  in  which  primary  carcinoma  of  the 
organ  was  associated  with  this  type  of  cirrhosis. 

Microscopic  Appearances. — The  most  striking  change  is 
the  overgrowth  of  fibrous  tissue  which  spreads  from  the  portal 
tracts,  forming  bands,  thicker  or  thinner,  cutting  off  individual 
lobules  or  groups  of  lobules.  This  fibrous  tissue  is  well  formed, 
but  it  often  shows  here  and  there  accumulations  of  small 


i88  DISEASES  OF  THE  LIVER 

round  cells,  indicating  that  the  fibrous  proliferation  is  still 
progressing.  There  is  considerable  development  of  new  elastic 
fibres  in  the  bands  of  fibrous  tissue.  There  is  a  varying 
number  of  small  bile  ducts.  These  in  some  cases  appear  to 
arise  from  retrograde  changes  in  columns  of  liver  cells,  the 
latter  reverting  to  their  embryonic  condition  under  the  pressure 
of  the  surrounding  fibrous  tissue.  In  other  cases  the  ducts 
represent  an  attempt  to  reform  liver  tissue,  just  as  in  subacute 
liver  atrophy.  There  is  a  tendency  for  the  fibrous  tissue  to 
invade  the  liver  lobule  at  its  margin  to  a  certain  small  extent, 
individual  liver  cells  or  groups  of  them  being  cut  off.  The 
liver  cells  themselves  commonly  show  more  or  less  fatty 
infiltration.  Not  infrequently  small  nodules  of  regenerated 
liver  tissue  are  met  with.  These  are  recognised  by  the 
evidence  of  multiplication  in  the  liver  cells,  some  of  them 
having  two  nuclei,  others  showing  evidence  of  division.  Such 
nodules  also  show  imperfect  lobule  formation. 

B.  Biliary  Cirrhosis. — This  condition  is  commonly  associ- 
ated with  obstruction  to  the  bile  ducts.  This  may  be  due  to  con- 
genital obliteration,  to  gall  stones,  or  to  tumour.  It  is  also 
very  commonly  associated,  as,  indeed,  obstruction  is,  with 
inflammatory  conditions  of  the  bile  ducts. 

The  organ  is  sometimes  enlarged,  sometimes  reduced  in 
size.  Its  surface  is  not  so  rough  as  in  common  cirrhosis.  It 
is  a  much  finer  cirrhosis,  corresponding  more  to  the  mono- 
lobular  type.  The  organ  usually  has  a  deep  yellow  colour , 
turning  green  on  exposure  to  the  air,  due  to  the  bile  staining 
which  so  constantly  accompanies  it.  The  organ  is  firmer 
and  tougher  than  normal.  On  section,  bands  of  fibrous 
tissue  can  be  seen  radiating  through  the  liver  tissue  and 
dividing  it  up  into  small  lobules  which  have  a  yellow  or 
green  colour.  Sometimes  abscess  formation  of  biliary  origin 
is  present. 

Microscopic  Appearances. — As  in  the  common  type,  the 
most  striking  change  is  an  overgrowth  of  the  fibrous  tissue  of 
the  organ,  extending  from  the  portal  tract  and  tending  to 


DISEASES  OF  THE  LIVER  189 

separate  individual  liver  lobules  from  one  another.  The  fibrous 
tissue  is,  on  the  whole,  more  cellular  than  in  the  common  type 
of  cirrhosis,  and  small  bile  ducts  are  a  more  conspicuous 
feature.  The  liver  cells  show  marked  degenerative  changes, 
areas  of  necrosis  being  frequently  met  with.  Bile  pigment 
may  be  seen  in  and  between  the  liver  cells.  Catarrhal  changes 
in  the  bile  ducts,  sometimes  with  the  development  of  abscesses, 
is  common.  In  suitably  stained  specimens  germs  may  be 
found,  especially  where  abscess  formation  is  present. 

C.  Syphilitic  Cirrhosis  (see  Syphilis). 

Results  of  Cirrhosis. — Owing  to  the  pressure  of  the  con- 
tracting fibrous  tissue  upon  the  branches  of  the  portal  vein 
within  the  liver,  there  is  obstruction  to  the  blood  passing 
through  the  organ  and  coming  from  spleen  and  bowel,  with 
the  following  results  : — 

i.  Ascites  or  dropsy  of  the  abdominal  cavity. 
^2.  Chronic   venous   congestion   of   oesophagus,   stomach, 
intestine,  and  spleen,  with  a  tendency  to  chronic  catarrh, 
varicose  veins,  haemorrhage,  and,  in  the  case  of  the  spleen, 
enlargement. 

These  two  changes  occur  especially  in  common  cirrhosis. 

3.  Jaundice,  which  is  more  characteristic  of  biliary  cirrhosis. 

Syphilis  of  the  Liver 

(a)  Congenital. — In  this  type  of  the  disease  a  diffuse 
cirrhotic  condition  is  sometimes  met  with  (congenital 
syphilitic  cirrhosis).  The  organ  is  enlarged,  commonly  bile- 
stained,  firmer  than  normal,  but  otherwise  little  altered. 

Microscopic  Appearances.  —  The  organ  is  the  seat  of  a 
diffuse  overgrowth  of  fibrous  tissue.  This  is  more  marked  in 
some  places  than  in  others.  It  is  not  specially  restricted  to 
the  portal  tracts  ;  on  the  contrary,  it  is  found  within  the  lobule 
separating  groups  of  cells  and  individual  cells  from  one 
another.  In  the  fibrous  tissue  are  to  be  found  numerous  small 
round  cells  aggregated  in  places  into  small  masses,  sometimes 


DISEASES  OF  THE  LIVER 

with  caseous  centres  (miliary  gummata).      In  suitably  treated 
material,  spirochaetes  may  be  demonstrated  in  large  numbers. 

(b)  Acquired. — In  acquired  syphilis  the  lesions  found 
in  the  liver  are  : — 

1.  Areas  of  chronic  perihepatitis }  sometimes  with  adhesions 
to  the  abdominal  wall  and  diaphragm. 

2.  Gummata. — These  are  caseous  foci  surrounded  by  a 
zone  of  fibrous  tissue   (Fig.   75),  sometimes  with  cirrhotic 
change  radiating  from  it  into  the  liver  substance.    They 
may  occur  singly  or  in  groups.    They  are  frequently  absorbed , 
leaving  behind  scars  which  show  themselves  as  puckerings 
on  the  surface.    When  these  are   numerous,  sometimes  a 
coarse  cirrhotic  condition  is  produced,  with  marked  deformity 
of  the  organ.    Waxy  degeneration  is  sometimes  combined 
with  the  above. 

Tuberculosis  of  the  Liver 

Tuberculosis  seldom  develops  to  any  extent  in  the  liver, 
that  organ  apparently  not  forming  a  suitable  nidus  for  the 
growth  of  the  tubercle  bacillus.  Two  types  of  the  disease 
are  found : — 

(a)  Miliary    Tuberculosis. — Small    scattered    foci    which 
may  or  may  not  be  visible  to  the  naked  eye.    When  visible, 
they  appear  as  minute  white  or  yellow  spots ;    sometimes 
they  are   bile-stained.     Similar  areas  are  found  in  other 
organs. 

Microscopic  Appearance.  —  Numerous  cellular  areas  are 
scattered  through  the  organ.  They  are  made  up  chiefly  of 
large  and  small  mononuclear  cells.  They  may  have  caseous 
necrotic  centres  or  may  show  giant  cells. 

(b)  Larger  caseous  nodules,  which  may  be  single  or  numer- 
ous, and  are  usually  bile-stained.    This  is  a  rare  type,  more 
commonly  met  with  in  children  than  in  adults. 


DISEASES  OF  THE  LIVER 


191 


Leukaemia  of  the  Liver 

The  organ  is  usually  enlarged,  paler  than  normal,  some- 
times with  distinct,  small,  whitish  areas  scattered  through  it. 

Microscopic  Appearances. — There  is  infiltration  of  the  liver 
substance  with  rounded  cells,  which  vary  in  type  according  to 
whether  the  condition  is  myelaemia  or  lymphsemia.  These 
cells  are  found  in  the  portal  tracts  and  between  the  columns 
of  liver  cells.  In  the  more  advanced  cases  the  individual 
liver  cells  may  be  separated  from  one  another.  Here  and 
there  are  cell  accumulations  without  any  liver  structure.  These 
are  the  above-mentioned  pale  areas.  The  endothelial  cells  of 
the  capillaries  are  swollen. 

Lymphadenoma  (Hodgkin's  Disease) 

The  liver  may  or  may  not  be  affected  in  this  condition. 
When  it  is,  numerous  irregularly  shaped  pale  areas  similar 
to  those  seen  in  the  spleen  are  scattered  through  it.  The 
condition  is  sometimes  indistinguishable  from  true  tumour 
formation.  In  most  cases,  however,  the  pale  areas  are  more 
diffusely  distributed,  smaller,  and  less  well  defined. 

Microscopically,  the  appearance  of  the  areas  is  similar  to 
those  found  in  the  spleen  in  the  same  disease  (see  p.  1 10). 

Tumours 

A.  Simple  growths  of  the  liver  are  not  common.  The 
cavernous  angioma  is  the  one  most  frequently  found.  It 
appears  as  a  dark  red  area  under  the  capsule  of  the  organ. 
On  section,  it  is  found  to  be  more  or  less  irregularly  wedge- 
shaped.  On  close  inspection,  bands  of  white  fibrous  tissue 
may  be  seen  dividing  the  area  up  into  spaces  filled  with 
blood  (Fig.  76).  Its  appearance  is  suggestive  of  an  infarct, 
but  it  should  be  remembered  that  true  infarction  of  the 
liver  does  not  occur. 

Adenomata  of  the  liver  are  occasionally  met  with.    They 


192  DISEASES  OF  THE  LIVER 

appear  as  circular,  well-defined  nodules  in  the  substance  of 
the  organ,  yellow  or  reddish-brown  in  colour.  They  are 
single  or  multiple,  and  microscopically  show  an  approxima- 
tion to  the  normal  structure  of  the  liver,  but  without  the 
regular  lobular  arrangement.  Areas  of  regenerated  liver 
tissue  have  a  somewhat  similar  appearance. 

B.  Malignant  growths  are  very  common  in  the  liver. 

Primary  growths  are  not  very  frequent,  but  secondary 
growths,  more  particularly  carcinomata,  are  very  common. 
The  venous  blood  from  the  various  portions  of  the  bowel 
passes  through  the  organ,  and  is  naturally  strained  of  any 
emboli,  tumour  or  otherwise,  in  it.  Inasmuch  as  the  malig- 
nant growth  of  the  bowel  is  almost  invariably  a  carcinoma, 
the  secondary  malignant  neoplasms  of  the  liver  are  commonly 
of  this  type. 

It  is  seldom  possible,  with  any  great  amount  of  certainty, 
to  decide  from  its  appearance  whether  a  tumour  is  sarcoma 
or  carcinoma,  primary  or  secondary.  The  growth,  or  growths, 
appear  as  white  or  yellow  areas  scattered  through  the  sub- 
stance of  the  organ,  varying  in  size,  rounded  or  irregular 
in  shape.  The  liver  is  often  greatly  enlarged  (Fig.  78).  In 
the  tumour  masses,  necrotic  areas,  and  haemorrhages  are 
commonly  seen.  Owing  to  sinking  in  of  the  necrotic  centres 
the  masses  on  the  surface  often  show  crater-like  hollows. 
The  intervening  liver  substance  frequently  shows  bile-staining, 
and  occasionally  cirrhosis.  The  connection  between  primary 
cancer  and  cirrhosis  is  well  recognised. 

1.  Primary  cancers  of  the  liver  are  of  two  types  : — 

(1)  A  type  resembling  more  or  less  "closely  the  structure 
of  the  liver,  the  tumour  cells  occurring  in  columns. 

(2)  A  type  arising  from  the  bile  ducts  and  resembling 
other  adeno-carcinomata. 

The  association  between  primary  cancer  and  cirrhosis  of 
the  liver  has  already  been  noted. 

2.  Secondary   cancers    vary    very    much   in    appearance 


DISEASES  OF  THE  LIVER  193 

and  in  character.  All  types  of  adeno-carcinoma  of  the 
bowel — columnar  cell,  scirrhous,  encephaloid,  colloid  occur, 
also  chorionepithelioma. 

Of  sarcomata  (Fig.  77)  only  the  melanotic  shows  appear- 
ances which  are  distinctive. 

Cysts  of  the  Liver 

Congenital  cystic  disease  is  sometimes  met  with  in  the 
liver,  although  not  so  frequently  as  in  the  kidney.  The 
cysts  are  numerous,  vary  in  size,  and  contain  clear  fluid. 

Hydatid  cysts  are  relatively  frequent  in  the  liver.  They 
often  attain  a  very  large  size,  are  surrounded  with  a  fibrous 
capsule,  and  contain  ecto-  and  endo-cyst,  with  the  character- 
istic "  white  of  egg  "  appearance  (Fig.  79). 

Gas  Cysts  of  small  size,  caused  by  the  development  of 
bubbles  of  gas  in  the  liver  substance  through  the  action  of 
an  organism  (B.  cerogenes  capsulatus,  also  called  B.  Welchit), 
are  occasionally  met.  They  are  found  in  association  with  sup- 
puration in  the  abdominal  cavity.  Pressure  upon  the  liver 
produces  a  sensation  of  crackling,  such  as  is  normally  present 
in  the  lungs.  Microscopically,  spaces  representing  dilated 
vessels  are  found  lined  with  a  layer  of  bacteria.  A  similar 
change  may  be  present  in  other  organs,  e.g.  pancreas. 

The  organism  causing  this  condition  is  a  normal  inhabitant 
of  the  intestinal  tract  and  is  often  found  in  the  blood  in  cases 
where  the  sectio  is  deferred  for  some  time  after  death.  The 
blood  in  such  cases  has  a  frothy  appearance.  Occasionally 
this  invasion  of  the  blood  occurs  during  life  when  the  above 
appearances  are  produced  in  the  liver  and  other  organs. 

METHOD  OF  EXAMINING  A  LIVER  REMOVED  FROM  THE  BODY 

The  general  size,  colour,  and  shape  of  the  organ  should  be 
noted,  also  the  appearance  of  the  lobules  as  they  shine  through 
the  capsule.  The  capsule  is  then  examined  for  evidence  of 

13 


I94          GALL  BLADDER  AND  BILE  DUCTS 

adhesions  with  the  abdominal  parietes,  for  depressions  such 
as  are  produced  by  gummata,  for  the  fine  or  coarse  generalised 
roughening  of  cirrhosis,  also  for  the  fibrinous  exudate  of 
acute  peritonitis  and  the  caseous  foci  of  tuberculous  peritonitis. 
The  organ  is  weighed ,  the  normal  weight  of  the  liver  being 
45  to  58  oz.  (1420-1649  grm.).  It  is  opened  up  by  a  series  of 
perpendicular  cuts.  In  so  doing  the  consistence  of  the  organ 
is  noted.  Pressure  is  made  upon  the  cut  surface  in  order 
further  to  investigate  this  point.  The  cut  edge  should  be 
looked  at  in  order  to  see  whether  it  is  rounded  (indicating 
soft  consistence)  or  sharp.  The  cut  surface  is  then  in- 
vestigated as  to  colour,  the  presence  of  abscesses,  tumours, 
etc.  Lastly,  the  gall  bladder  is  opened  up,  and  the  amount  of 
bile,  also  its  colour  noted.  Gall  stones  should  be  searched  for. 

DISEASES  OF  GALL  BLADDER  AND  BILE  DUCTS 

Congenital  obliteration  of  the  common  bile  duct  is  a 
condition  occasionally  met  with.  The  exact  cause  is  unknown, 
but  it  is  believed  to  be,  in  some  cases,  syphilitic  in  origin. 
It  is  associated  with  a  fine  cirrhosis  of  the  liver  and  bile 
pigmentation  of  that  organ  as  well  as  jaundice. 

Inflammation  of  Gall  Bladder  (Cholecystitis),  of  Bile 
Ducts  (Cholangitis). 

Catarrhal  Inflammation. —  A  mild  degree  of  inflamma- 
tion of  the  bile  passages  is  sometimes  associated  with  a 
catarrhal  condition  of  the  stomach,  and,  owing  to  the  low 
pressure  at  which  the  bile  is  excreted,  blocking  of  the  bile 
passages  from  swelling  of  the  walls,  with  resulting  jaundice, 
may  occur.  A  similar  condition  is  sometimes  brought  about 
by  the  invasion  of  organisms,  such  as  the  B.  typhosus'm 
typhoid  fever.  The  bacilli,  in  all  probability,  reach  the  bile 
ducts  from  the  blood  by  way  of  the  liver,  but  it  is  possible 
that  they  pass  upwards  from  the  duodenum.  In  the  gall 


GALL  BLADDER  AND  BILE  DUCTS  195 

bladder  and  larger  bile  ducts  a  catarrhal  inflammation  is 
set  up  which  may  persist  for  months  or  years  after  the  attack 
of  fever.  In  many  instances  this  inflammatory  change  leads 
to  gall-stone  formation.  When  the  typhoid  bacillus  is  the 
cause  of  this  condition  the  patient  suffering  from  it  is  con- 
stantly voiding  with  his  stools  living,  virulent  organisms, 
which  may  contaminate  food  or  drink  and  lead  to  the  dis- 
semination of  the  disease.  Such  individuals  are  known  as 
"  typhoid  carriers" 

Suppurative  inflammation  of  the  bile  ducts  (suppurative 
cholangitis)  is  a  very  common  accompaniment  of  obstruction 
to  the  outlet  of  the  bile  from  gall  stones  or  tumour  formation. 
The  organisms  found  are  usually  staphylococci  or  B.  coli. 
The  condition  results,  not  infrequently,  in  abscesses  (biliary) 
within  the  liver  substance. 

Suppurative  Inflammation  (empyema)  of  the  gall  bladder 
is  sometimes  met  with  apart  from  cholangitis.  The  acute 
inflammation  may  pass  through  the  wall  of  the  bladder  and 
give  rise  to  acute  peritonitis. 

Biliary  Concretions  or  Gall  Stones  (Cholelithiasis) 

Gall  stones  are  much  more  common  in  women  than 
in  men,  something  like  three-quarters  of  the  cases  occurr- 
ing in  the  female  sex.  They  usually  make  themselves 
felt  about  the  age  of  forty,  although,  not  infrequently,  the 
stones  are  found  post-mortem  without  there  being  in  the 
history  of  the  case  anything  to  indicate  their  presence.  As 
regards  causation,  tight  lacing,  good  living,  and  sedentary 
habits  are  predisposing  factors,  but  the  actual  cause  of  the 
condition  is  commonly  a  catarrhal  inflammation  of  the  bile 
passages  associated  with  the  presence  of  organisms.  Aschoff 
distinguishes  two  types  of  gall  stones  :  (i)  Those  produced 
by  congestion  of  bile  and  disturbances  of  metabolism ;  the 
stones  belonging  to  this  category  consist  almost  entirely 


196          GALL  BLADDER  AND  BILE  DUCTS 

of  cholesterin.  (2)  Those  caused  by  inflammatory  change 
due  to  the  presence  of  organisms.  The  germs  which  have 
been  separated,  in  some  cases  actually  from  the  interior 
of  the  stones  themselves,  are  staphylococci,  B.  coli,  and  B. 
typhosus.  The  mode  of  formation  of  the  concretions  is  as 
follows  :  a  nucleus  of  mucus  and  epithelial  debris  is  formed, 
and  round  this  are  deposited  cholesterin  (largely  derived  from 
disintegrated  epithelium),  lime  and  magnesium  salts,  and  bile 
pigment.  Cholesterin  is  the  main  constituent,  being  present 
usually  to  the  amount  of  70-80  per  cent ;  hence  the  lightness 
of  the  stones.  Some  stones  are  formed  almost  entirely  of 
cholesterin.  The  colour,  which  varies  from  pale  yellow  to 
black,  depends  upon  the  amount  of  bile  pigment  present. 
The  concretions  vary  much  in  size,  from  minute  particles 
(gall  sand)  to  masses  measuring,  it  may  be,  two  inches  across. 
Those  formed  in  the  bile  ducts  are  usually  small ;  the  larger 
ones  develop  in  the  gall  bladder.  Gall  stones  are  usually 
multiple,  hence  commonly  facetted  (Fig.  80).  Sometimes 
they  have  a  mulberry-like  surface  and  occasionally  they  are 
smooth.  The  smooth  stones  are,  of  course,  solitary.  On 
section,  the  concretions  often  show  concentric  lamination; 
sometimes  they  exhibit  radiating  lines. 

As  regards  the  effects  of  the  presence  of  gall  stones,  they 
tend  to  keep  up  the  chronic  irritation  which  caused  their 
formation.  Thus  they  lead  to  thickening  of  the  gall  bladder 
and  bile  ducts  and  to  adhesions  to  surrounding  parts.  More 
acute,  suppurative  inflammation  may  be  set  up.  They  may 
ulcerate  through  into  the  intestine,  and,  when  very  large, 
have  been  known  to  cause  intestinal  obstruction.  They 
may  obstruct  the  cystic  duct,  thus  leading  to  atrophy,  or,  in 
some  cases,  to  dilatation  of  the  gall  bladder.  They  not 
infrequently  obstruct  the  common  bile  duct  and  give  rise 
to  jaundice.  Lastly,  there  is  a  very  definite  relationship 
between  cancer  of  the  gall  bladder  and  the  presence  of  gall 
stones. 


DISEASES  OF  THE  PANCREAS  197 

Tumours. — The  carcinoma  is  the  most  important  tumour  of 
the  gall  bladder.  It  is  usually  a  columnar  cell  adeno-car- 
cinoma,  but  may  be  a  scirrhus  or  colloid  cancer,  or  even  a 
squamous  epithelioma. 


DISEASES  OF  THE  PANCREAS 

The  pancreas  is  an  organ  which  tends  to  show  marked  post- 
mortem changes,  partly  because  of  the  action  of  the  digestive 
juices  which  it  secretes,  partly  because  of  its  proximity  to 
stomach  and  intestine,  and  so  to  infection  with  putrefactive 
germs.  Thus,  just  as  in  the  case  of  the  stomach,  so  with  the 
pancreas,  the  pathologist  must  be  careful  not  to  regard  as 
evidence  of  disease,  changes  which  are  merely  due  to  altera- 
tions taking  place  after  death. 

Where  a  lesion  of  the  pancreas  is  suspected,  careful  search 
should  be  made  for  areas  of  fat  necrosis.  Conversely,  the 
presence  of  these  areas  of  fat  necrosis s  is  evidence  of  a 
lesion  of  the  pancreatic  gland.  Such  areas  are  found  in  the 
fat  of  the  pancreas  itself,  of  the  mesentery  and  omentum, 
occasionally  even  of  the  mediastinum.  They  appear  as 
opaque  white  spots  the  size  of  pin  heads,  or  even  as  large  as 
peas.  The  change  in  the  fat  is  brought  about  by  a  setting 
free  in  the  peritoneal  cavity  of  the  fat-splitting  ferment  of 
the  pancreas.  The  neutral  fat  is  at  first  split  into  fatty  acid 
and  glycerine,  the  fatty  acid  probably  combining  subsequently 
with  a  calcium  base. 

Atrophy  of  the  pancreas  is  sometimes  met  in  old  age 
and  wasting  diseases.  In  diabetes  not  infrequently  the  only 
alteration  found  is  a  diminution  in  the  size  of  this  organ. 

Fatty  infiltration,  or  penetration  of  fat  into  the  sub- 
stance of  the  gland,  with  atrophy  of  the  gland  tissue,  is 
occasionally  seen. 


igS  DISEASES  OF  THE  PANCREAS 

Inflammation 

1.  Acute  H&morrhagic  Pancreatitis. — This  is  a  somewhat 
rare  condition,  the  etiology  of  which  is  not  quite  clear.    The 
symptoms   are   those   of   acute   intestinal   obstruction.     In 
many  instances  it  is  an  acute  infective  process  due  to  the 
presence  of  germs,  and  it  is  not  infrequently  found  in  associa- 
tion with  cholangitis  and  gall  stones  which  may  be  found 
blocking  the  ampulla  of  Vater.     Some  regard  the  haemorrhage 
as  the  primary  change,  others  consider  that  it  is,  like  the  fat 
necrosis,  due  to  the  setting  free  of  the  digestive  juices  of  the 
organ,  and  the  action  of  these  upon  the  blood-vessels. 

As  regards  appearances,  the  organ  is  swollen  and  dark  red 
in  colour,  due  to  infiltration  with  blood.  More  or  less  extensive 
fat  necrosis  is  always  found  in  the  fat  in  the  neighbourhood. 

Microscopically,  areas  of  necrosed  pancreatic  tissue  are 
found,  also  infiltration  of  the  interacinous  tissue  with  red  blood 
corpuscles,  fibrin,  and  leucocytes.  The  areas  of  fat  necrosis 
are  well  brought  out  with  Nile  Blue  which  stains  the  necrosed 
fat  blue,  the  normal  fat  red. 

2.  Suppurative  Pancreatitis. — Organisms  may  reach  the 
pancreas  by  way  of  the  blood-stream  or  by  the  duct  of  Wirsung, 
or  again  by  extension  from  neighbouring  parts.    The  abscesses 
may  be  minute  and  numerous  or  large  and  solitary.    Some- 
times the  change  is  associated  with  suppurative  cholangitis 
and  gall  stones.    The  abscesses  may  rupture  into  the  peri- 
toneal cavity  and  cause  peritonitis. 

3.  Chronic   interstitial    pancreatitis    or    cirrhosis    of    the 
pancreas  may  be  met  with  in  association  with  alcoholism, 
syphilis,  and  obstruction  to  the  duct  of  Wirsung  by  calculi 
or  tumour  formation.     In  some  cases  of  diabetes  a  fine 
fibrosis,  involving  more  especially  the  islands  of  Langerhans, 
has  been  described. 

Tumours. — Primary  carcinomata  are  occasionally  met 
with.  By  pressure  upon  the  common  bile  duct  such  tumours 


DISEASES  OF  THE  PANCREAS  199 

cause  an  extreme  degree  of  jaundice.  Many  of  the  cases  of 
so-called  malignant  jaundice  are  due,  not  to  a  neoplasm  in 
the  pancreas,  but  to  some  secondary  deposit  in  a  retroperi- 
toneal  gland  in  the  neighbourhood.  As  a  rule  carcinomata 
show  microscopically  the  characters  of  a  columnar  cell 
glandular  cancer. 

Cysts. — The  pancreas,  like  the  liver  and  kidneys,  is 
sometimes  the  seat  of  congenital  cystic  disease.  Such  cysts 
are  multiple  and  small.  Large  solitary  cysts  are  also  met  with, 
due  in  all  probability  to  obstruction  of  a  duct  of  the  gland. 

Relationship  between  Lesions  of  the  Pancreas  arid  Diabetes. — 
Since  the  middle  of  last  century  a  relationship  between  changes 
in  the  pancreas  and  the  disease  diabetes  has  been  recognised. 
In  1889  it  was  shown  by  Minkowski  that  total  extirpation  of 
the  organ  produced  a  fatal  diabetes.  Ligature  of  the  duct 
was,  however,  found  not  to  have  this  effect.  It  was  concluded 
that  the  pancreas  gave  origin  to  an  internal  secretion  which, 
in  cases  of  diabetes,  was  absent.  Search  was  made  for  some 
element  in  the  gland  which  might  be  the  source  of  such  an 
internal  secretion,  and  the  islands  of  Langerhans,  first  observed 
in  1869,  were  selected  as  the  probable  source.  Somewhat 
conflicting  statements  are  at  present  made  regarding  the 
presence  of  lesions  of  these  structures  in  diabetes.  Some  have 
found  fibrosis  or  hyaline  degeneration  in  a  large  proportion  of 
cases.  There  can  be  no  doubt  that  in  many  cases  no  obvious 
lesion  of  any  structure  in  the  pancreas  can  be  found.  The 
lesions  which  have  been  described  are  simple  atrophy,  fatty 
infiltration  associated  with  atrophy,  a  fine  fibrosis,  hyaline 
change  in  the  connective  tissue  of  the  islands  of  Langerhans. 


CHAPTER  X 

DISEASES   OF  THE   KIDNEY   AND   BLADDER 

DISEASES  OF  THE  KIDNEY 

CONGENITAL  ANOMALIES 

Persistence  of  Foetal  Lobulation  is  a  fairly  common  finding. 
It  is  best  seen  after  stripping  the  capsule  from  the  organ, 
and  shows  itself  by  a  series  of  intersecting  lines  dividing  the 
organ  into  irregularly  shaped  areas. 

Horse-shoe  Kidney,  a  condition  in  which  the  two  organs 
are  united,  usually  at  their  lower  end  across  the  vertebral 
column,  is  not  infrequently  found. 

Congenital  Cystic  Kidney. — In  this  condition,  which  is 
always  bilateral,  the  organ  is  enlarged,  often  greatly  so.  The 
outer  surface  is  studded  with  projecting  cysts,  with  trans- 
parent contents  varying  in  size  from  something  just  visible 
to  a  walnut.  In  some  cases  there  is  very  little  kidney  tissue 
left  between  the  cysts.  On  section,  a  similar  appearance 
is  seen  (Fig.  81).  The  condition  is  believed  to  be  due  to  a 
failure  of  union  between  the  glomerular  and  the  tubular 
portions  of  the  kidney  tissue,  which  are  developed  separ- 
ately. 

Solitary  congenital  cysts,  sometimes  of  large  size,  may 
be  met  with. 

200 


DISEASES  OF  THE  KIDNEY  201 

Congenital   Hydronephrosis   may  occur  in  one  kidney 
owing  to  defective  formation  of  the  ureter. 


CIRCULATORY  CHANGES 

1.  Chronic  Venous  Congestion. — This  condition  is  found 
in  cases  where  there  is  obstruction  to  the  passage  of  blood 
through  the  heart  or  lungs. 

Naked-eye  Appearances. — The  organ  is  somewhat  enlarged. 
It  is  firm.  On  section,  the  medulla  has  a  dark  purple  appear- 
ance, the  cortex  is  paler  than  the  medulla,,  but  shows  dark  lines 
and  dots  indicating  vessels  and  glomeruli.  On  stripping  the 
capsule,  the  venae  stellatae  are  often  very  prominent. 

Microscopic  Appearances. — The  vessels  generally  are  dilated, 
more  especially  those  of  the  medulla.  The  glomerular  capil- 
laries are  distended.  Sometimes  haemorrhages  into  the 
tubules  are  seen.  Catarrhal  and  interstitial  changes  may  be 
superadded. 

2.  Infarction. — Infarcts  of  the  kidney  are  common.    They 
are  almost  invariably  due  to  embolism  of  one  of  the  branches 
of  the  renal  artery.     Occasionally  the  whole  vessel  may  be 
blocked.    The  embolism  may  be  caused  by  the  impaction 
of  portions  of  thrombi  from  vegetations  on  the  aortic  or 
mitral  valve,  thrombi  in  the  left  auricle  or  its  appendix,  or 
on  atheromatous  patches  in  the  aorta.    The  infarcts  are 
wedge-shaped  areas  in  the  cortex,  usually  white  or  yellow 
in  appearance,  surrounded  by  a  haemorrhagic  zone,  more 
especially  where  they  come  in  contact  with  the  medulla 
(Fig.  82).    At  first  the  area  is  level  with  the  rest  of  the  surface. 
Later  on  it  becomes  depressed,  and  eventually  absorbed, 
leaving  a  cicatrix. 

Very  similar  irregularly  scattered  depressed  areas  are  found 
on  the  surface  of  the  organ  which,  on  section,  prove  to 
be  areas  where  the  cortex  is  narrow  and  fibrosed.  They  are 
due  to  interstitial  change  following  blocking  of  vessels  owing 


202     DISEASES  OF  THE  KIDNEY  AND  BLADDER 

to  disease.    This  condition  when  well  marked  is  usually 
referred  to  as  arterio-sclerotic  kidney  (see  p.  214). 

Microscopic  Appearance.  —  The  infarcted  portion  shows 
swelling,  granularity,  and  more  intense  staining  of  the  columnar 
cells  of  its  tubules.  The  nuclei  usually  are  broken  into 
masses  of  chromatin  or  fail  to  stain  altogether.  At  the  margin 
the  tubules  and  intertubular  tissue  are  infiltrated  with  red 
blood  cells,  and  frequently  with  leucocytes.  The  thrombosed 
vessel  can  often  be  seen  towards  the  apex  of  the  wedge. 
When  the  embolus  contains  organisms  these  may  be  seen  in 
masses.  In  such  a  case  polymorphonuclear  leucocytes  are 
very  numerous. 

DEGENERATIONS 

1.  Cloudy  Swelling. — This  is  found  in  all  infective  diseases. 
It  is  particularly  well  marked  in  cases  of  pneumonia. 

The  organ  is  somewhat  enlarged,  softer,  and  more  friable 
than  normal.  On  section,  the  cortex  is  pale,  opaque,  and 
swollen.  The  cut  surface  of  the  cortex  protrudes  above  the 
level  of  the  medulla. 

Microscopic  Appearances.  —  The  condition  affects  most 
markedly  the  cells  of  the  convoluted  tubules,  i.e.  the  largest 
columnar  cells.  Such  cells  are  swollen  and  project  into  the 
lumen  of  the  tubule  giving  a  characteristic  star-like  appear- 
ance. Their  protoplasm  is  granular.  The  nucleus  in  some 
cases  stains  more  intensely,  in  others  it  is  paler  than  usual. 
Sections  stained  for  fat  will  often  show  a  few  globules 
within  the  cells.  There  is  a  tendency  to  separation  of 
the  cells  lining  the  tubules  owing  to  loosening  of  cement 
substance,  and  occasionally  cells  may  be  thrown  off  into  the 
lumen  of  the  tubule.  Where  this  last  change  is  a  prominent 
feature  the  term  catarrhal  nephritis  is  applicable.  In  fact 
there  is  no  hard-and-fast  line  between  cloudy  swelling  and 
parenchymatous  or  catarrhal  nephritis  (see  p.  209). 

2.  Fatty. — Two  forms  of  this  condition  may  be  distin- 
guished, although  no  very  hard-and-fast  line  can  be  drawn 
between  them. 


DISEASES  OF  THE  KIDNEY  203 

(1)  Primary  fatty  degeneration  caused  by  organisms  and 
their  products,  and  therefore  found  in  infective  conditions 
often  as  a  sequel  to  cloudy  swelling  ;  caused  also  by  chemical 
poisons  such  as  phosphorus  and  chloroform. 

(2)  Fatty  change  secondary  to  catarrh  of  the  tubules,  and 
found  in  association  with  Bright's  disease  and  waxy  degenera- 
tion. 

Naked-eye  Appearances. — In  the  first  condition  there  is 
usually  no  great  alteration  in  size  in  the  organ.  On  section, 
the  cortex  is  pale  opaque-white  in  appearance,  and  contrasts 
with  the  more  vascular  medulla. 

In  the  second  variety  the  appearances  depend  upon  the 
stage  of  the  disease,  and  will  be  described  in  connection  with 
the  various  types  of  nephritis  and  waxy  change. 

Microscopic  Appearances. — In  sections  stained  by  ordinary 
methods,  such  as  haematein  and  eosin,  the  cells  of  the  convoluted 
tubules  appear  swollen  and  granular,  and  their  nuclei  may  show 
degenerative  changes.  In  sections  stained  with  Sudan  III.  or 
Scharlach  R.  the  same  cells  will  be  found  to  show  numerous 
fat  granules  and  globules,  more  especially  in  the  deeper  part 
of  their  protoplasm.  In  the  collecting  and  other  forms  of 
tubules  the  same  change  will  be  found,  but  less  marked. 

3.  Waxy  (Amyloid). — This  may  be  found  in  association 
with  advanced  tuberculosis,  visceral  syphilis,  or  chronic 
suppuration,  e.g.  empyema,  bone  or  joint  disease. 

The  kidney  is  usually  enlarged,  in  the  more  advanced  stages 
very  markedly  so,  although,  when  combined  with  interstitial 
change,  it  may  be  reduced  in  size.  It  is  pale  from  anaemia 
and  associated  fatty  change  (frontispiece,  Fig.  6).  As  a  rule 
it  is  firm,  and  shows  a  sharp  edge  on  section ;  occasionally  it 
may  be  soft.  The  appearances  are  very  similar  to  those 
seen  in  the  subacute  form  of  Bright's  disease  (large  white 
kidney).  In  some  instances  it  is  possible  to  distinguish 
between  the  two  conditions  only  on  testing  with  iodine. 
Sometimes  the  glomeruli  can  be  seen  as  minute  translucent 


204     DISEASES  OF  THE  KIDNEY  AND  BLADDER 

specks.  In  the  more  advanced  stages  the  whole  cut  surface 
has  a  translucent  appearance.  On  treatment  with  iodine  the 
glomeruli  and  vessels  are  brought  out  as  mahogany  brown 
specks  and  lines.  The  capsule  commonly  strips  well  and 
leaves  a  smooth,  pale,  mottled  surface. 

Microscopically,  the  change  is  observed  first  in  the  afferent 
arterioles  (see  plan,  p.  206)  ;  it  then  spreads  to  the  glomeruli 
and  efferent  vessels,  and  also  to  the  middle  coat  of  the  larger 
arteries.  The  arteriolae  rectae  in  the  medulla  are  early  affected. 
In  the  advanced  stages  of  the  disease  the  basement  membrane 
of  the  tubules,  the  periendothelial  connective  tissue  of  the 
intertubular  capillaries,  and  other  strands  of  supporting  fibrous 
tissue  are  implicated.  The  waxy  material  is  homogeneous 
and  translucent  when  unstained.  It  appears  yellow  with 
transmitted,  dark  brown,  with  reflected  light  after  treatment 
with  iodine,  and  gives  a  rose  pink  to  purple  colour,  with  methyl 
violet  and  subsequent  differentiation  in  dilute  acid.  There  is 
usually  a  considerable  amount  of  fatty  change,  catarrh  of  the 
tubules,  and,  in  the  later  stages,  overgrowth  of  fibrous  tissue. 

4.  Pigmentary  Changes. —  In  pernicious  anaemia  the 
kidney,  like  the  liver  and  spleen,  may  be  the  seat  of  the 
deposit  of  hsemosiderin.  In  jaundice  the  kidney  is  the  first 
organ  to  be  affected  and  shows  a  yellow  tinge  which  becomes 
green  on  exposure  to  the  air. 

INFLAMMATION  OF  THE  KIDNEY  OR  NEPHRITIS 

General  Facts. — The  kidney  is  an  organ  essentially  con- 
cerned with  the  elimination  of  waste  products  of  metabolism 
and  poisonous  substances.  In  any  condition  in  which  poisons 
are  circulating  in  the  blood,  whether  these  be  of  chemical 
nature  or  bacterial  origin,  the  organ  is  apt  to  be  damaged. 
Once  this  damage  has  occurred  and  the  eliminating  function 
of  the  organ  interfered  with,  matters  are  made  worse,  for  the 
irritating  poison  accumulates,  as  do  also  waste  products  of 
metabolism  which  further  injure  the  delicate  secreting  tissue. 
Thus  a  vicious  circle  tends  to  be  set  up,  which  intensifies  the 
action  of  the  poisonous  substance. 


DISEASES  OF  THE  KIDNEY  205 

There  are  two  other  eliminating  channels  for  waste  products 
in  the  body— the  lungs  and  the  skin.  These  to  a  certain 
small  extent  are  capable  of  taking  on  vicariously  the  function 
of  the  kidney,  but  only  to  a  very  minor  extent.  Thus  in  cases 
of  kidney  insufficiency  the  breath  and  the  sweat  may  contain 
urea.  The  converse  also  holds  good,  in  that  when  elimination 
by  the  skin  is  interfered  with  more  work  is  thrown  upon  the 
kidney.  Thus,  on  passing  from  a  warm  atmosphere  where  the 
skin  is  acting  freely  into  a  cold  one,  there  is  a  sudden  change 
of  the  excretory  responsibility  from  the  one  organ  to  the  other. 
In  addition,  the  internal  organs,  among  them  the  kidney,  tend 
suddenly  to  be  flooded  with  more  blood,  owing  to  the  contrac- 
tion of  the  cutaneous  vessels.  In  this  way  it  is  possible  to 
understand  the  causation  of  nephritis  through  chill. 

The  kidney  is  a  very  vascular  organ,  and  one  which  is 
specially  dependent  upon  its  blood-supply  for  the  integrity  of 
its  secreting  tissue.  Thus  any  localised  disease  of  the  vessels 
of  the  organ  or  any  general  vascular  change  implicating  the 
renal  vessels  will  tell  detrimentally  upon  its  function,  and  will 
produce  structural  changes  of  the  nature  of  degeneration  in 
the  secreting  epithelium  with  subsequent  replacement  of 
this  by  fibrous  tissue.  Thus,  extensive  vascular  disease 
is  accompanied  inevitably  by  alterations  in  the  kidney.  The 
converse  also  holds  good.  When  the  kidney  is  damaged, 
products  of  metabolism  are  retained  within  the  circulation 
which  irritate  and  damage  the  vessels,  leading  to  thickening 
and  degenerative  changes.  Thus  vascular  and  renal  conditions 
very  frequently  coexist,  and,  inasmuch  as  the  condition  of  the 
vessels  affects  the  heart,  cardiac  disease  is  eventually  super- 
added. 

The  vascular  supply  of  the  organ  is  peculiar,  and  it  is  well 
to  remember  this,  as  it  affords  a  means  of  understanding  how 
structural  changes  may  follow  alterations  in  blood-supply.  The 
renal  arches  which  pass  between  cortex  and  medulla  give  off  from 
their  cortical  aspect  branches  known  as  interlobular ;  from  the 
medullary  aspect  come  the  arteriolae  rectse,  which  pass  down- 
wards into  the  medulla.  The  interlobular  arteries  give  off  the 
afferent  arterioles  which  supply  the  glomeruli.  The  blood 
leaves  the  glomerulus  at  the  same  point  as  it  enters  it  by  the 
efferent  vessels.  The  glomerulus  is  a  bag  of  coiled  capillary 


206    DISEASES  OF  THE  KIDNEY  AND  BLADDER 

vessels  with  a  narrow  neck,  through  which  the  blood  enters  and 
leaves  the  structure.  But  the  blood  does  not  at  once  return 
to  the  veins  by  the  efferent  channel.  The  vessel  again  breaks 
up  into  a  series  of  capillaries  (see  plan),  supplying  the 
kidney  tubules  with  blood.  Thus  any  interference  with  the 
flow  of  blood  through  the  glomerulus  will  inevitably  tell  upon 
the  tubules  leading  to  degenerative  changes  in  these.  Such 


AA. 


RV. 


Plan  of  the  Circulation  in  the  Kidney. 


R.A.,  branch  of  renal  artery;  I. A.,  interlobular  artery;  A.A.  afferent  arteriole  ; 
G.,  glomerulus;  E.A.,  efferent  arteriole  ;  I.C.,  interlobular  capillaries;  T.,  tubule  ; 
V.,  venous  rootlets;  R.V.,  branch  of  renal  vein;  A.,  arteriae  rectae ;  V.R.,  venae 
rectae. 

interference  may  be  rapid  in  its  onset  from  sudden  circulatory 
disturbances  as  in  "  chill,"  or  slowly  progressing  from  a  gradual 
narrowing  of  the  vessel  lumen. 

Causation. — The  causes  of  nephritis  thus  are  : — 
i.  Chemical  poisons,  such  as  alcohol,  lead,  cantharides, 
taken  into  the  body ;   also  poisons  formed  by  the  body  itself, 
such  as  abnormal  products  of  metabolism  or  normal  products 
present  in  excess,  as  in  the  disease  commonly  called  gout. 


DISEASES  OF  THE  KIDNEY  207 

2.  Bacteria  and  their  poisons  in  process  of  excretion,  as 
in  the  specific  fevers,  scarlet  fever,  typhoid,  small-pox,  etc. 

3.  Bacteria  multiplying  locally,  as  in  suppurative  nephritis 
and  tuberculosis. 

4.  Circulatory    alterations,     acute    congestion    associated 
with  "  chill,"  and,  to  a  certain  extent,  chronic  venous  con- 
gestion. 

Classification. — It  is  customary  and  convenient  to  dis- 
tinguish two  primary  groups :  (i)  Organismal  nephritis, 
where  the  germs  are  actually  present  and  multiplying  in  the 
organ.  Of  this  there  are  two  main  types  :  (a)  septic  nephritis, 
and  (b)  tuberculosis  of  the  kidney.  (2)  Non-organismal 
nephritis,  that  is  to  say,  where  the  germs,  although  they  may 
be  present,  are  not  multiplying  in  the  organ.  In  the  commonest 
type  of  this  disease  there  may  be  no  germs  or  bacterial  poisons 
at  all,  the  condition  being  due  to  sudden  alterations  in  the 
circulation  of  the  blood  or  to  toxins.  This  non-organismal 
type  of  nephritis  corresponds  to  what  is  usually  called  "  Bright 's 
disease." 

Bright's  disease  may  be  divided,  according  to  the  stage 
of  the  disease,  or  rather  the  degree  of  acuteness,  into  three 
subgroups :  (a)  acute  nephritis,  (b)  subacute  nephritis,  and 
(c)  chronic  nephritis.  Of  these  subgroups  (a)  may  pass  into 
(b),  and  (a)  and  (b)  into  (c).  There  is  no  hard-and-fast  line 
between  them,  and  as  a  result  transitional  types  are  not 
infrequently  met  with.  The  method  is,  however,  useful  for 
purposes  of  classification  and  description.  As  Bright's  disease 
is  the  most  important  type  of  nephritis  it  will  be  considered 
first. 

Types. 

I.  Non-organismal  nephritis  (Bright's  Disease). 
i.  Acute. 

(a)  Glomerular. 

(b)  Tubular  or  catarrhal. 

(c)  Interstitial. 


208    DISEASES  OF  THE  KIDNEY  AND  BLADDER 

2.  Subacute  (large  white  kidney). 

3.  Chronic  interstitial  (granular  contracted). 

Sub-group — Arteriosclerotic. 
Amyloid  degeneration  may  occur  in  combina- 
tion with  Nos.  2  and  3. 
II.  Organismal  Nephritis. 

1.  Acute  (septic  nephritis). 

(a)  Embolic  or  pysemic. 

(b)  Pyelonephritis  (surgical  kidney). 

2.  Tuberculosis. 

(a)  Embolic  or  miliary. 

(b)  Tuberculous   pyelonephritis    or   chronic 
tuberculosis. 

3.  Syphilis. 

Acute  Nephritis 

In  studying  the  microscopic  changes  in  the  kidney 
in  nephritis,  and  in  describing  these  changes,  it  is  well 
to  remember  that  there  are  three  more  or  less  distinct 
structures  or  types  of  tissue  in  the  organ,  (a)  the  tubules, 
(b)  the  glomeruli,  (c)  the  supporting,  interstitial  fibrous 
tissue  carrying  the  vessels.  The  poisons  which  cause  nephritis 
tend  to  exercise  a  selective  faculty  to  a  certain  extent,  and 
one  finds  that  in  one  case  the  tubules  are  more  affected,  in 
another  the  glomeruli,  and  in  a  third  the  interstitial  tissue. 
For  example,  the  poison  of  scarlet  fever  has  a  special  tendency 
to  affect  the  glomeruli.  Of  course  this  is  true  only  up  to  a 
certain  point.  These  structures  are  closely  related  to  one 
another,  and  it  is  almost  inconceivable  that  a  poison  could 
affect  one  and  not  another,  and  as  a  matter  of  fact  they  are 
all  affected  to  a  certain  degree  in  all  cases.  But  in  given 
instances  one  structure  may  show  such  marked  changes 
that  one  is  warranted  in  taking  these  changes  as  a  basis  for 
classification.  Thus  three  subgroups  of  acute  nephritis 
may  be  distinguished  :  (a)  glomerular,  (b)  tubular,  (c)  inter- 


DISEASES  OF  THE  KIDNEY  209 

stitial.  As  a  matter  of  fact,  the  naked-eye  appearances, 
never  very  characteristic  in  acute  nephritis,  do  not  differ 
to  any  extent  in  the  three  types. 

Naked-eye  Appearances.— These,  as  already  mentioned, 
are  not  very  characteristic.  In  some  cases  the  organ  presents 
very  little  by  way  of  variation  from  the  normal.  In  other 
cases  the  appearances  are  merely  those  of  a  well-marked 
cloudy  swelling. 

As  regards  size  the  organ  is  usually  somewhat  swollen, 
and  in  certain  cases  swelling  may  be  a  very  marked  feature. 
It  is  softer  than  usual  and  may  be  paler  or  congested.  On 
section,  in  many  cases  (probably  in  most)  the  cortex  is 
swollen,  opaque  white,  or  pale  yellow,  contrasting  markedly 
with  the  congested  medulla  (Fig.  83).  There  may  be  small 
haemorrhages  scattered  through  the  cortex.  In  other  cases 
the  whole  organ  is  deeply  congested  and  filled  with  blood, 
which  drips  from  the  cut  surface.  The  capsule  shows  no 
alteration  and  strips  readily  from  the  organ,  leaving  a  smooth 
surface.  Occasionally  the  Malpighian  bodies  are  prominent. 

Microscopic  Appearances — (a)  Tubular  Changes.  —  The 
cells  lining  the  tubules  are  swollen  and  granular.  Many  of 
them  have  become  thrown  off,  and  are  found  lying  free  within 
the  lumen  of  the  tube.  Some  of  the  collecting  tubules  may 
be  filled  up  with  these  desquamated  cells.  In  suitably 
stained  specimens,  fat  globules  in  varying  amounts  will  be 
found  within  the  cells,  both  those  still  attached  and  those  lying 
free.  In  the  more  acute  types  of  the  condition  the  nuclei 
show  degenerative  changes,  as  evidenced  by  pale  staining  or 
complete  loss  of  staining  reaction.  In  the  less  acute  types 
there  may  be  evidence  of  nuclear  division.  In  many  cases 
there  is  a  granular  exudate  present  within  the  lumen  of  the 
tubules.  In  all  cases  the  degenerative  changes  tend  to  be 
more  marked  in  the  convoluted  tubules. 

(b)  Glomerular  Changes. — In  many  instances  these  are 
slight.  There  is  swelling,  and  possibly  desquamation  of  the  cells 
covering  the  tuft  and  of  those  lining  Bowman's  capsule.  There 
is  congestion  of  the  capillaries  of  the  tuft,  and  increase  of  the 

14 


210  DISEASES  OF  THE  KIDNEY  AND  BLADDER 

number  of  cells  in  the  tuft  owing  to  the  presence  of  leucocytes. 
In  other  cases  more  extensive  glomerular  changes  are  present — 
desquamation  and  proliferation  of  the  cells  covering  tuft  and 
lining  the  capsule.  Haemorrhage  into  the  space  between  tuft 
and  capsule  may  be  found. 

(c)  Interstitial  Changes. — The  vessels  are  distended  with 
blood.  There  tends  to  be  more  or  less  infiltration  of  the 
intertubular  supporting  tissue  with  cells,  chiefly  small,  round, 
lymphocyte-like  cells.  Where  this  latter  change  is  a  marked 
feature,  the  term  "  acute  interstitial  nephritis "  has  been 
applied. 

All  the  above  changes  have  a  tendency  to  be  irregular  in 
their  distribution,  being  often  more  intense  in  one  part  of  the 
cortex  than  in  another. 

Changes  in  the  Urine  in  Acute  Nephritis. — The  amount 
secreted  is  diminished.  In  colour  it  is  "  smoky  "  to  dark 
red,  owing  to  admixture  with  blood.  On  standing  it  deposits 
a  sediment  which  contains  hyaline,  epithelial,  and  blood  tube 
casts,  red  blood  corpuscles  and  free  epithelial  cells.  Albumin 
is  usually  abundant.  The  total  amount  of  urea  excreted 
is  considerably  diminished. 

Subacute  Nephritis— Large  White  Kidney 

Acute  nephritis  passes  by  almost  insensible  gradations 
into  the  subacute  type.  The  latter  may  follow  the  acute 
condition  or  it  may  develop  insidiously.  The  causes  are 
the  same  in  the  two  types.  Once  degenerative  changes 
have  begun  in  the  kidney,  products  of  metabolism  are 
retained.  These,  accumulating,  act  themselves  as  poisons 
upon  the  renal  cells.  Thus  a  vicious  circle  is  established. 
It  is  much  more  difficult  for  matters  to  return  to  the  normal 
in  the  case  of  the  kidney  once  degenerative  processes  have 
commenced  than  it  is  in  the  case  of  any  other  glandular 
organ. 

Naked-eye  Appearances. — The  organ  is  enlarged  and  pale. 
Hence  the  terms  "  large  pale/'  "  large  white  "  kidney.  This 


DISEASES  OF  THE  KIDNEY  211 

increase  in  size  may  be  slight,  but  in  many  cases  it  is  very 
marked.  It  is  firm  in  consistence  and  the  surface  is  smooth. 
Through  the  capsule,  which  is  not  thickened,  the  pallor  of 
the  cortex  can  be  made  out,  also  the  superficial  veins,  which 
are  sometimes  prominent.  On  section,  the  most  striking 
change  is  the  swelling  of  the  cortex,  both  superficial  and  inter- 
pyramidal  (Fig.  84).  The  cortex  may  be  twice  the  usual 
breadth.  In  other  cases  there  is  no  great  alteration  in 
diameter.  It  has  an  opaque  white  appearance,  and  presents 
a  marked  contrast  to  the  medulla,  which  has  the  usual  dark 
red  colour.  Portions  of  the  cortex,  representing  groups  of 
tubules  with  more  marked  fatty  change,  have  a  more  opaque 
appearance.  Thus  there  is  often  a  mottling  of  the  cortex. 
The  line  between  cortex  and  medulla  is  well  defined.  The 
capsule  is  not  usually  thickened,  and  on  stripping,  which  is 
easily  carried  out,  it  leaves  a  smooth  surface  behind. 

Microscopic  Appearances — (a)  Tubules. — The  epithelium 
lining  the  tubules  tends  to  be  of  a  lower  type.  That  is  to  say, 
instead  of  being  columnar,  it  is  cubical,  or  even  flattened.  It 
may  show  evidence  of  multiplication.  Many  of  the  cells  are 
cast  off  and  lying  free  in  the  lumen.  In  suitably  stained 
specimens  fat  will  be  found  present  in  many  cells,  particularly 
in  those  which  have  been  thrown  off,  and  especially  in  the 
cells  of  the  convoluted  tubules.  Globules  of  fat  are  also  to  be 
found  in  the  stroma.  Evidence  of  nuclear  degeneration  is  not 
so  prominently  present  as  in  the  acute  stage.  Some  of  the 
tubules  contain  transparent,  hyaline,  homogeneous  casts. 

(b)  Glomeruli. — The  changes  in  the  glomeruli  are  usually 
well  marked,  although  less  marked  in  some  cases  than  in 
others.  There  is  multiplication  of  the  cells  lining  Bowman's 
capsule,  and  of  those  covering  the  tuft,  so  that  frequently  a 
number  of  layers  of  cells  are  present  between  the  capsule  and 
the  capillary  tuft.  These  cells  may  contain  fat.  In  other 
cases  there  is  a  fibrous  change  in  the  glomerulus.  Connective 
tissue  is  laid  down  within  the  structure,  with  the  result  that  it 
becomes  transformed  into  a  fibrous  knot.  Both  these  changes 
are  not  infrequently  present  in  the  same  case. 


212    DISEASES  OF  THE  KIDNEY  AND  BLADDER 

(c)  Interstitial. — The  intertubular  and  interglomerular  tissue 
is  uniformly  increased.  This  new  tissue  is  fairly  cellular,  con- 
taining considerable  numbers  of  small  round  cells,  scattered 
and  in  groups.  This  is  occasionally  the  predominant  change 
when  the  term  "  subacute  interstitial  nephritis  "  may  be  em- 
ployed to  characterise  the  condition. 

The  vessels  may  show  a  beginning  of  the  thickening 
which  is  so  prominent  a  feature  of  chronic  nephritis.  This 
thickening  involves  both  the  inner  and  middle  coats. 

Waxy  disease  is  not  infrequently  associated  with  subacute 
nephritis. 

Changes  in  the  Urine  in  Subacute  Nephritis. — The  amount 
is  diminished.  The  total  amount  of  urea  excreted  is  re- 
duced. Albumin  is  present,  usually  in  large  amount. 
Blood  is  sometimes  present.  The  deposit  shows  large 
numbers  of  tube  casts  (fatty,  granular,  colloid  and 
hyaline),  leucocytes,  epithelial  cells,  and  sometimes  red 
blood  corpuscles.  As  the  condition  becomes  more  chronic 
the  urine  tends  to  show  the  characters  found  in  chronic 
interstitial  nephritis. 


Chronic  Interstitial  Nephritis 

This  condition  may  follow  one  or  other  of  the  previous 
types,  or  it  may  arise  slowly  and  insidiously  as  the 
result  of  the  action  of  some  irritant  circulating  in  the 
blood-stream.  Such  irritants  are  alcohol,  lead,  and  pro- 
ducts of  metabolism  which  are  not  being  got  rid  of,  as  in 
gout.  There  is  a  very  intimate  relationship  between  this  type 
of  nephritis  and  arterial  disease.  It  is  not  always  possible 
to  decide  which  condition  is  the  primary  one.  Certainly 
arterial  disease  may  lead  to  renal  changes  such  as  are  found 
in  chronic  nephritis,  but  just  as  certainly  arterial  changes 
may  be  the  result  of  renal  inadequacy,  products  of  meta- 
bolism not  being  excreted  by  the  kidney,  and  leading  to 
arterial  degeneration.  Or  again,  the  two  sets  of  changes 


DISEASES  OF  THE  KIDNEY  213 

may  advance  pari  passu,  being  due  to  one  and  the  same 
cause. 

The  causes  of  chronic  nephritis  may  thus  be  summed  up  : — 

1.  The  condition  may  follow  acute  or  subacute  nephritis, 
and  the  cause  may  thus  be  the  same. 

2.  Chronic  toxaemias  :  alcohol,  lead,  gout. 

3.  Arterial  disease. 

Inasmuch  as  the  main  change  in  this  condition  is  a  fibrosis 
or  replacement  of  the  kidney  tissue  by  connective  tissue,  the 
term  "  chronic  interstitial  nephritis  "  is  generally  applicable, 
and  on  account  of  the  appearance  of  the  organ  the  term 
"  granular  contracted  kidney  "  is  sometimes  used. 

The  essential  nature  of  the  process  in  chronic  nephritis, 
just  as  in  cirrhosis  of  the  liver,  is  the  degeneration  and  dis- 
appearance of  the  secreting  elements,  and  the  replacement 
of  them  by  fibrous  tissue.  This  may  be  brought  about  by 
chronically  acting  poison,  but  is  not  infrequently  secondary 
to  interference  with  the  blood-supply.  Thus  sclerotic 
changes  in  a  glomerulus  will  inevitably  lead  to  interference 
with  the  nutrition  of  the  tubules  around  which  its  efferent 
vessel  breaks  up.  Similarly  endarteritis  in  the  interlobular 
arteries  will  act  by  causing  malnutrition  of  the  area  supplied. 

Naked-eye  Appearances. — The  kidney  is  always  reduced 
in  size,  sometimes  very  markedly  so.  It  may  be  adherent 
to  the  peri-renal  tissue,  and  thus  present  some  difficulty  in 
removal.  It  is,  of  course,  lighter  in  weight  than  normal. 
Instead  of  the  normal  5  ounces  it  may  weigh  3  or  even  2  ounces. 
The  surface  is  more  or  less  rough,  and  usually  shows  a  varying 
number  of  small  cysts  under  the  capsule.  On  cutting  into  it 
the  organ  is  found  to  be  tougher  than  usual.  The  cut  surface 
presents  great  variation  in  colour  in  different  cases,  and  the 
changes  are  not  always  uniform,  but  there  are  certain  funda- 
mental alterations  which  are  commonly  present.  In  the  first 
place  the  cortex  is  narrowed,  more  especially  the  superficial 
cortex  (Fig.  85).  In  colour,  as  already  stated,  the  kidney  varies. 


214  DISEASES  OF  THE  KIDNEY  AND  BLADDER 

In  some  cases  there  is  no  great  alteration,,  in  others,  where 
congestion  of  vessels  is  present,  the  organ  is  more  intensely 
red  than  normal ;  in  other  cases,  again,  where  tubular  changes 
of  an  acute  or  subacute  type  are  superadded  to  the  chronic 
process  the  cortex  may  be  pale.  Sometimes  the  colour  of  the 
organ  in  general,  and  of  the  cortex  in  particular,  is  employed 
as  a  basis  of  classification  ;  thus  the  terms  small  red  and  small 
white  kidney  are  used.  Such  terms  are  unnecessary.  A 
striking  point  is  that  there  is  not  the  usual  difference  in  colour 
between  cortex  and  medulla,  nor  is  there  the  usual  line  of 
demarcation.  The  two  seem  to  pass  into  one  another.  The 
larger  vessels  at  the  line  of  junction  between  cortex  and 
medulla  are  thickened  and  project,  and  the  lines  of  the  inter- 
lobular  arteries  passing  upwards  into  the  cortex  are  tortuous. 
This  irregularity  in  the  vessel  markings  is  very  character- 
istic. There  is  in  many  cases  an  increase  in  the  fat  around 
the  pelvis  of  the  kidney.  This  is  due  to  a  shrinkage  of  the 
organ  away  from  the  pelvis,  the  place  of  the  kidney  tissue 
being  taken  by  the  fat.  As  a  result  the  organ  is,  if  one  may 
use  the  expression,  smaller  than  it  looks  from  the  outside. 
The  capsule  of  the  organ  is  usually  more  or  less  thickened  and 
shows  abnormal  attachment  to  the  surface  of  the  kidney,  so 
that  in  stripping  the  capsule,  portions  of  the  kidney  tissue 
may  be  removed  with  it.  In  other  cases  this  adherence  of 
the  capsule  is  not  marked,  but  in  all  cases  the  surface  of  the 
organ  when  stripped  of  the  capsule  shows  more  or  less  irregu- 
larity (Fig.  86).  This  roughening  may  be  slight  (morocco- 
leather  appearance)  or  it  may  be  very  marked.  The  sub- 
capsular  cysts,  already  mentioned,  will  be  obvious  on  removing 
the  capsule.  They  contain  a  clear  colourless  fluid. 

Arterio-sclerotic  kidney  is  the  name  applied  to  a 
special  type  of  chronic  nephritis  associated  with,  and  be- 
lieved to  be  subsequent  to,  advanced  chronic  arterial  disease. 
The  kidney  in  this  condition  is  often  red  and  the  roughening 
of  the  surface  and  the  narrowing  of  the  cortex  is  irregular  in 


DISEASES  OF  THE  KIDNEY  215 

its  distribution.  Thus  there  are  areas  of  extreme  narrowing 
of  the  cortex,  with  marked  depression  of  the  surface  corre- 
sponding to  the  distribution  of  those  vessels  which  show 
most  marked  narrowing  of  their  lumen.  Other  areas  of 
the  organ  are  comparatively  normal. 

Microscopic  Appearances.  —  A  striking  fact  on  examining 
large  sections  of  such  kidneys  under  the  microscope  is  the 
variation  in  the  appearances  seen  in  one  part  from  those  seen 
in  another.  Areas  will  be  found  in  which  the  alterations  are 
slight,  alternating  with  areas  in  which  they  are  marked.  In 
the  early  stage  of  the  condition  wedge-shaped  areas  of  inter- 
stitial change  will  be  found  extending  inwards  from  the  cortex. 
In  the  more  advanced  stages  this  is  exaggerated,  areas  of 
marked  fibrosis  alternating  with  areas  more  or  less  normal  in 
appearance.  In  other  cases  the  interstitial  change  is  diffuse. 

(a)  Changes  in  the  Tubules. — The  epithelium    lining    the 
tubules  is  cubical  rather  than  columnar,  and  shows  more  or 
less  evidence  of  catarrhal  change.      In  some  cases  where  an 
acute    or    subacute  attack   has   been  superimposed  upon  the 
chronic  process  the  catarrhal  changes  are  marked.      Many  of 
the  tubules  contain   hyaline   or  colloid  casts.      In   the    more 
condensed  areas  the   tubules   are  compressed  and  narrowed. 
In  the  intervening  portions  of  the  cortex  the  tubules  are  more 
normal  in  size  or,  in  many  instances,  dilated,  and  the  cells 
lining   them   are  often  enlarged.      Sometimes  dilated  tubules 
show  papillomatous  projections  into  their  lumen. 

(b)  Changes  in  the  Glomeruli. — These  consist  in  a  fibroid 
change,  all  stages  of  which  may  be  seen.     In  the  earlier  stage 
the  capillaries  of  the  structure  are  still  visible  although  their 
walls   are  thickened.     In  the  later   stage   the  glomerulus    is 
reduced  to  a  knot  of  fibrous  tissue,  which  may  show  hyaline 
alteration,   and   often  contains  no  cells.     Again    this  change 
shows  irregularity  in  its  distribution.      It  is  more  marked  in 
the  condensed  areas,  less  marked  in  the  intervening  portions. 

(c)  Interstitial  Changes. — These  consist  in  an  overgrowth 
of  fibrous  tissue.     In  the  earliest  stage  this,  as  a  rule,  occurs 
in  wedge-shaped  areas  extending  inwards   from   the  capsule. 
The  fibrous  tissue  is  well  formed,  although  accumulations  of 
small  round  cells  may  occur.     The  vessels  show  more  or  less 


216    DISEASES  OF  THE  KIDNEY  AND  BLADDER 

obvious  alteration.  As  a  rule  this  is  most  marked  in  the 
intima,  and  consists  in  a  thickening,  with  narrowing  of  the 
lumen.  At  the  same  time  the  middle  and  outer  coats  tend  to 
be  thickened.  These  alterations  are  seen  in  vessels  of  all  sizes. 
Sometimes  in  cases  where  the  organ  has  a  red  appearance 
the  intertubular  capillaries  are  dilated. 

In  the  arteriosclerotic  type  the  vascular  changes  are  more 
marked,  otherwise  the  appearances  are  very  similar. 

The  overgrowth  of  fibrous  tissue  occurs  round  tubules  and 
glomeruli  as  well  as  in  the  neighbourhood  of  vessels.  Oc- 
casionally the  fibrous  change  occurs  diffusely  throughout  the 
organ. 

Changes  in  the  Urine  in  Chronic  Interstitial  Nephritis. — 
The  amount  tends  to  be  increased.  The  urine  is  pale  and 
has  a  low  specific  gravity.  The  amount  of  urea  is 
diminished.  As  a  rule  no  blood  is  present  and  albumin 
is  scanty;  sometimes  there  is  merely  a  trace.  The  centri- 
fugalised  deposit  shows  only  occasional  tube  casts.  These 
are  chiefly  hyaline  or  granular. 

Pathological  Conditions  associated  with  Nephritis 

Cardiac  Changes. — In  acute  nephritis  degenerative  changes 
may  be  met  with  in  the  heart  muscle  due  to  the  action  of  the 
toxic  agent  which  also  causes  the  nephritis.  At  any  stage 
of  the  disease  pericarditis  and  endocarditis  may  occur  as 
complications.  The  most  common  alteration  in  the  heart , 
and  one  that  is  specially  characteristic  of  the  chronic  form  of 
nephritis,  is  hypertrophy  of  the  left  ventricle.  This  is  due 
largely  to  the  associated  arterial  sclerosis. 

Arterial  Changes. — These  consist  in  a  thickening  of  the 
medium-sized  and  smaller  vessels  which  in  the  earlier  stages 
is  probably  due  largely  to  a  contraction  and  thickening  of 
the  media,  in  the  later  stages  to  a  fibrous  transformation  of 
the  media  and  to  a  thickening  of  the  intima  of  an  athero- 
matous  type.  The  frequent  association  of  chronic  interstitial 
nephritis  with  atheroma  is  well  illustrated  by  a  series  of  144 


DISEASES  OF  THE  KIDNEY  217 

cases  recorded  by  Lorrain-Smith  of  which  67-6  per  cent 
showed  atheroma  of  one  or  more  groups  of  vessels.  The 
hypertrophy  of  the  left  ventricle  and  the  arterial  thickening 
are  both  associated  with  the  rise  in  blood  pressure  which  is  so 
characteristic  of  the  more  chronic  types  of  renal  disease. 
In  connection  with  this  it  may  be  noted  that  in  cases  of 
cerebral  haemorrhage  of  the  variety  found  in  older  people  some 
degree  of  chronic  nephritis  as  well  as  arterial  disease  and  hyper- 
trophy of  the  left  ventricle  may  be  confidently  looked  for. 

Blood  Changes. — An  anaemia  of  the  secondary  type  occurs 
in  all  cases  of  subacute  and  in  many  cases  of  chronic  nephritis. 

Lung  Changes. — Pneumonia  and  pleurisy  are  not  un- 
common complications  of  kidney  disease.  (Edema  is  also 
common,  and  is  a  not  infrequent  cause  of  death. 

Dropsy. — Abnormal  accumulation  of  fluid  in  the  lymphatic 
spaces  and  in  the  serous  cavities  is  very  constantly  met  with 
in  nephritis,  both  in  its  acute  and  in  its  subacute  manifesta- 
tions. In  chronic  interstitial  nephritis,  so  long  as  the  heart 
does  not  fail,  oedema  is  not  a  prominent  feature.  The 
oedema  of  nephritis  is  probably  due  to  a  combination  of  a 
number  of  factors  : — 

(1)  Damage  to  the  endothelial  lining  of  the  vessel  from 
the  circulation  in  it  of  poisonous  waste  products. 

(2)  A  watery  condition  of  the  blood,  due  to  the  anaemia. 

(3)  Feeble  action  of  the  heart. 

(4)  Retention  of  salt  in  the  tissues. 

The  cedema  often  shows  itself  in  situations,  such  as  round 
the  eye,  where  the  tissue  is  loose,  but  it  may  spread  and 
involve  the  whole  subcutaneous  tissue  (anasarca),  the  serous 
cavities,  and  lungs.  The  oedema  of  nephritis  is  relatively 
soft  to  the  touch.  In  the  later  stages  of  chronic  nephritis  a 
dropsy  having  the  distribution  and  character  of  cardiac 
dropsy  may  appear.  It  is  more  connected  with  the  failing 
heart  than  with  the  kidney  condition. 

Changes  in  Connection  with  the  Nervous  System. — In  cases 


218  DISEASES  OF  THE  KIDNEY  AND  BLADDER 

which  die  with  symptoms  of  uraemia,  oedema  of  the  brain 
is  commonly  present.  In  all  cases  albuminuric  retinitis 
should  be  looked  for.  This  shows  itself  in  the  form  of  minute 
haemorrhages  in  the  retina.  As  already  stated,  cerebral 
haemorrhage  is  a  frequent  cause  of  death  in  cases  of  chronic 
interstitial  nephritis.  Of  the  above-mentioned  series  of 
144  cases  55  died  of  cerebral  haemorrhage. 

Tube  Casts 

These  structures,  so  characteristic  of  nephritis  in  all 
its  stages,  are  casts  of  the  kidney  tubules  occurring  in 
these  or  in  the  urine.  In  order  to  examine  for  their 
presence  the  urine  should  be  centrifugalised  or  allowed 
to  deposit  for  some  hours.  A  little  of  the  sediment  is 
then  removed  with  a  pipette  and  placed  on  a  slide  under 
the  microscope.  In  order  to  see  the  tube  casts  properly 
an  ordinary  high  power  lens  should  be  used,  and  the  iris 
diaphragm  of  the  sub-stage  should  be  shut  to  a  consider- 
able extent.  The  following  varieties  of  tube  casts  may  be 
distinguished  : — 

(1)  Hyaline   Casts   are   difficult   to   see   owing   to   their 
transparency.    They  may  occur  in  the  acute  type  of  nephritis, 
being  formed  of  an  exudation  from  the  blood.    They  form 
the  basis  for  other  types  of  casts,  such  as  the  cellular  variety. 
In  the  later  subacute  or  chronic  stages,  transparent  casts  with 
a  sharper  outline  are  also  met  with.    They  are  often  spoken 
of  as  colloid  or  waxy  casts.    They  are  due  to  changes  occurring 
in  shed  and  long  retained  epithelium. 

(2)  Cellular  Casts. — These  may  consist  of  (a)  red  blood 
corpuscles,  (b)  leucocytes,  (c)  desquamated  epithelium,  or 
of  a  mixture  of  these.    They  are  characteristically  present 
in  the  acute  and  subacute  stages  of  the  disease. 

(3)  Fatty  Casts  are  produced  by  fatty  change  occurring 
in   cellular  casts   of  the   epithelial   type.    They  are   most 
characteristic  of  subacute  nephritis. 


DISEASES  OF  THE  KIDNEY 


219 


(4)  Granular  Casts. — These  are  found  mainly  in  subacute 
and  chronic  nephritis.    They  are  due  to  changes  occurring  in 
cellular  casts.    They  may  also  be  produced  by  the  deposit 
of  granules  of  urates  upon  hyaline  casts. 

(5)  Crystalline  and  Pigmentary  Casts  are  occasionally  met. 


TABLE  OF  COMPARISON  BETWEEN  THE  VARIOUS  TYPES  OF 
BRIGHT'S  DISEASE. 


Acute  Nephritis. 

Subacute  Nephritis 
or  Large  White 
Kidney. 

Chronic  Interstitial 
Nephritis  or  Granular 
Contracted  Kidney. 

Size  of  organ. 

Slight  swelling. 

Considerable  en- 
largement. 

Reduction  in  size, 
often  very  small. 

Consistence. 

Softer  than  nor- 
mal. 

Firm. 

Tough. 

Appearance  of 
cortex. 

Varies  consider- 
ably.     Often 
pale     as     in 
cloudy  swell- 
ing.    May  be 
congested. 

Greatly  increased 
in     breadth, 
pale        and 
mottled. 

Always    narrowed, 
colour      varies, 
pale  or  red. 

Capsule. 

Non-adherent. 

Thickened     and 
often  adherent. 

Surface     after 
stripping. 

Smooth. 

Always  rough,  usu- 
ally   with    small 

Vessels. 

Not  as  a  rule  altered. 

cysts. 
Thickened,  cut  ends 

prominent. 

Peripelvic  fat. 

Not  altered. 

Increased. 

Associated 
Conditions. 

(Edema  of  brain,  other  forms  of 
dropsy  ;     inflammatory    condi- 
tions, e.g.  pneumonia,  pericar- 
ditis, etc. 

Arteriosclerosis  ; 
hypertrophy     of 
left   ventricle  ; 
cerebral    haemor- 
rhage. 

220  DISEASES  OF  THE  KIDNEY  AND  BLADDER 

Suppurative  Nephritis 

This  is  a  form  of  nephritis  in  which  germs  themselves 
are  present  and  are  multiplying  in  the  kidney  tissue.  It  is 
associated  with  more  or  less  obvious  suppurative  foci  or 
abscesses. 

There  are  clearly  two  paths  by  which  bacteria  may  reach 
the  kidney  tissue — the  blood-stream  and  the  ureter.  Thus 
there  are  two  types  of  suppurative  nephritis. 

i.  Hcematogenous  Suppurative  Nephritis  —  Pycemic  or 
Embolic  Abscesses  of  the  Kidney. — This  condition  is  associated 
with  the  presence  of  organisms  in  the  circulating  blood — with 
pyaemia,  ulcerative  endocarditis,  etc.  The  suppurative  foci 
are  usually  numerous  and  irregularly  scattered  through  both 
kidneys.  Occasionally  the  abscesses  may  occur  in  groups, 
or  even  one  group,  and  the  condition  may  be  limited  to  one 
organ.  The  germs  found  are  those  associated  with  pyaemia 
and  ulcerative  endocarditis  (see  p.  64). 

Naked-eye  Appearances. — The  organ  may  be  slightly 
enlarged,  and  is  somewhat  softer  than  normal.  On  section, 
opaque  yellow  foci  are  found  scattered  through  cortex  and 
medulla  quite  irregularly  or  in  groups  (Fig.  87).  These  foci 
vary  in  size,  but  are  usually  minute,  and  are  surrounded  by 
a  zone  of  congestion  and  haemorrhage.  The  intervening 
portions  of  cortical  substance  are  pale.  The  capsule  strips 
well  and  the  abscesses  are  often  particularly  well  seen  (Fig.  88) 
from  the  outer  aspect.  Infarcts  are  not  infrequently 
associated. 

Microscopic  Appearances.—  All  the  appearances  of  an  acute 
nephritis  are  present.  There  is  marked  cloudy  swelling  and 
catarrhal  change  in  the  tubules,  and,  in  the  neighbourhood  of 
suppurative  foci,  actual  necrosis.  The  most  striking  change, 
however,  is  an  acute  interstitial  change,  the  fibrous  structures 
being  infiltrated  with  numbers  of  cells,  chiefly  polymorpho- 
nuclear  leucocytes.  This  change  is  intensified  in  parts  so 


DISEASES  OF  THE  KIDNEY  221 

that  the  kidney  tissue  disappears,  and  its  place  is  taken  by  a 
mass  of  leucocytes — in  other  words,  there  is  an  abscess.  In 
the  centre  of  this  area  masses  of  germs  are  not  infrequently 
found,  and  around  the  mass  of  leucocytes  a  zone  of  haemorrhage 
occurs.  The  vessels  generally  are  congested.  Leucocytes 
may  also  be  found  within  the  lumen  of  tubules. 

2.  Suppurative  Pyelonephritis  or  Surgical  Kidney. — In 
this  type  the  infective  agent  arrives  by  way  of  the  ureter. 
It  is  thus  associated  with  inflammation  of  the  bladder, 
ureter,  and  pelvis  of  the  kidney.  It  is  usually  bilateral,  but 
is  often  more  marked  on  one  side  than  on  the  other.  It 
may  occur  in  cases  of  cystitis  due  to  infection  by  the  passing 
of  a  catheter.  It  is  thus  found  in  connection  with  obstruc- 
tion to  the  urinary  passages  from  stricture  or  enlarged 
prostate.  It  not  infrequently  follows  lesions  of  the  spinal 
cord  where  there  is  loss  of  control  of  the  bladder  and  the  urine 
dribbles  away.  Organisms  readily  pass  up  the  tract  under 
these  conditions  and  infect  first  the  bladder,  then  the  ureter, 
the  pelvis  of  the  kidney,  and  kidney  itself.  The  organisms 
found  are  very  frequently  inhabitants  of  the  lower  bowel ; 
thus  B.  coli  is  very  commonly  present,  also  streptococci) 
siaphylococcij  etc. 

Naked-eye  Appearances. — The  organ  is  often  enlarged, 
soft,  and  pale.  It  may,  however,  be  abnormally  small  from 
pre-existing  chronic  nephritis.  On  section,  pus  is  found  in 
the  pelvis,  which  may  show  thickening,  injection  of  vessels, 
fibrinoiis  exudation,  or  haemorrhage,  but  which  frequently 
shows  no  very  obvious  alteration.  Running  up  into  the 
medulla  are  yellow  lines  representing  spread  of  the  sup- 
purative  process  into  the  pyramids.  In  the  cortex  are 
similar  but  more  rounded  areas  (abscesses)  with  a  zone  of 
haemorrhage  surrounding  them.  The  intervening  portions 
of  cortex  are  pale.  The  capsule  may  or  may  not  strip  easily 
according  as  chronic  interstitial  changes  are  present  or  not. 
The  abscesses  are  often  well  seen  from  the  outer  surface. 


222    DISEASES  OF  THE  KIDNEY  AND  BLADDER 

Microscopically^  the  changes  are  precisely  similar  to  those 
found  in  the  previous  type. 

Tuberculosis  of  the  Kidney 

Two  types  of  tuberculosis  of  the  kidney  may  be  dis- 
tinguished. 

1.  A  type  associated  with  blood  infection,  and  therefore 
with  miliary  tuberculosis   of  other   organs.     In  this  type 
there  are  small,  scattered  white  or  yellow  foci,  usually  minute, 
and  mainly  in  the  cortex. 

Microscopically,  these  are  found  to  be  typical  tubercle 
follicles  with  giant  cells  or  caseous  centres  (see  p.  138). 

2.  Tuberculous  Pyelonephritis  or  Chronic  Tuberculosis. — 
This  type  may  be  associated  with  tuberculosis  of  the  lung 
or  other  organs.    Not  infrequently,  however,  the  lesions,  in 
the  renal  tract,  are  the  most  striking  manifestation  of  the 
disease.      The  condition  of  the   kidney  is  very  frequently 
associated  with  tuberculosis  in  other  parts  of  the  uro-genital 
tract,  with  tuberculosis  of  testicle,  vesiculae  seminales,  vas 
deferens,  bladder,  and  ureter.     Undoubtedly  in  some  cases 
the  infection  is  an  ascending  one,  but  in  many  cases  the 
bladder  may  be  infected  from  the  kidney. 

Naked-eye  Appearances. — The  appearances  vary  much 
according  to  the  stage  of  the  disease.  The  condition  may 
be  limited  to  one  kidney ;  in  most  cases  it  is  more  advanced 
in  one  organ  than  in  the  other.  The  organ  may  be  enlarged 
and  is  usually  pale.  The  change  begins  in  the  pelvis  in  most 
cases,  and  spreads  backwards  into  the  substance  of  the  organ. 
The  pelvis  is  thus  lined  with  caseous  necrotic  material,  and 
scattered  through  the  kidney  substance  are  fibro-caseous 
foci  (Fig.  89).  Destruction  of  the  kidney  substance  proceeds 
with  the  formation  of  cavities  or  excavations  (Fig.  90).  In 
advanced  cases  the  organ  may  be  transformed  into  a  bag 
containing  structureless  caseous  material. 


DISEASES  OF  THE  KIDNEY  223 

The  condition  is  sometimes,  in  its  more  acute  manifestations, 
difficult  to  distinguish  from  suppurative  nephritis.  The  foci 
in  tuberculosis  tend,  however,  to  be  firmer,  more  yellow,  and 
to  stand  out  more  from  the  surrounding  kidney  tissue. 

Microscopically,  the  changes  are  those  usually  associated 
with  the  more  chronic  types  of  tuberculosis — fibrosis,  tubercle 
follicles,  and  caseous  foci. 

Syphilis  of  the  Kidney. — In  some  cases  of  syphilis  a 
diffuse  interstitial  nephritis  may  be  met  with.  This  may  or 
may  not  be  combined  with  amyloid  disease.  Gummata  of 
the  kidney  occasionally  occur. 

Leukaemia  of  the  Kidney. — In  some  cases  of  leukaemia 
the  kidney  undergoes  little  or  no  alteration.  In  other  cases, 
more  especially  in  the  lymphatic  type,  the  changes  may  be 
extreme. 

In  a  well-marked  case  of  leukaemia  kidney  the  organ  is 
enlarged  and  pale  (one  type  of  large  white  kidney)  and  through 
it  and  under  its  capsule  are  scattered  numerous  hemorrhages. 
The  characteristic  appearance  of  the  cut  surface  of  the  organ 
is  to  a  great  extent  lost. 

Microscopically,  there  is  a  marked  infiltration  of  the  organ 
with  round  cells,  lymphocytes,  or  myelocytes,  as  the  case  may 
be,  with  a  separation  of  the  kidney  structures — glomeruli  and 
tubules  —  from  one  another.  Areas  of  infiltration  with  red 
blood  corpuscles  are  also  met  with. 

Tumours. 

Simple  tumours  are  infrequent,  with  the  exception  of 
small  fibromata  of  the  medulla  of  the  kidney,  which  are  very 
common  and  appear  as  small  white  rounded  areas.  Adeno- 
mata occasionally  occur. 

Of  malignant  growths  sarcomata  are  more  common  than 
cancers.  They  are  specially  frequent  in  children. 


224  DISEASES  OF  THE  KIDNEY  AND  BLADDER 

Rhabdomyomata  or  striped  muscle  tumours  of  sarcomatous 
nature  are  occasionally  met  with. 

Hypernephromata  are  among  the  commonest  type  of  kidney 
growth.  They  occupy  a  position  by  themselves.  They  are 
believed  to  arise  from  suprarenal  rests.  Such  rests  are 
not  infrequently  found  under  the  capsule  of  the  kidney  as 
small  yellow  spots.  The  hypernephroma  varies  very  much 
in  size  and  appearance.  It  usually  has  opaque  yellow  areas 
resembling  the  cortex  of  the  suprarenal  in  appearance, 
mixed  often  with  hsemorrhagic  areas  and  brownish  areas  of 
necrosis  (Fig.  92).  The  tumour  is  undoubtedly  simple  in 
many  cases,  but  in  others,  where  it  attains  a  very  large  size, 
it  shows  malignant  characters. 

Microscopically,  the  appearances  of  the  hypernephroma 
vary  a  good  deal,  but,  as  a  rule,  the  cells  contain  a  large 
amount  of  fat,  myelin,  etc.,  are  vacuolated,  and  generally  show 
some  approximation  to  the  appearance  of  the  cells  in  the  cortex 
of  the  suprarenal. 

METHOD  OF  EXAMINING  A  KIDNEY  REMOVED  FROM 
THE  BODY 

Having  removed  all  adherent  fat  which,  except  in  cases  of 
chronic  interstitial  nephritis,  is  easily  done,  note,  in  the  first 
instance,  the  size  of  the  organ  and  its  weight.  The  normal 
kidney  measures  about  4^  inches  (11-12  cm.)  in  length, 
2  inches  (5-6  cm.)  in  breadth,  and  ij  inches  (3-4  cm.)  in 
thickness.  The  average  weight  is  5^  ounces  (150  gm.). 
Next  examine  the  surface  for  any  gross  irregularities,  yellow 
areas  under  capsule  indicating  suprarenal  rests  and  cysts  or 
cicatrices.  Holding  the  organ  in  the  left  hand,  with  the  hilum 
towards  the  palm,  cut  it  longitudinally  with  a  large  knife  from 
its  convexity  to  the  pelvis,  taking  care  not  to  injure  the  glove 
or  the  hand  which  is  holding  the  organ  (see  Fig.  13).  While 
cutting,  note  the  consistence  of  the  kidney  tissue.  Examine 
the  cut  surface,  attending  to  the  following  points  : — 

(i)  The  cortex,  its  breadth  relative  to  that  of  the  medulla. 
This  should  be  as  one  to  three,  the  cortex  measuring  about 


DISEASES  OF  THE  PELVIS  OF  THE  KIDNEY  225 

one-fifth  of  an  inch  (5-6  mm.)  in  width.  Its  colour,  which 
should  be  reddish-brown,  somewhat  paler  than  the  medulla.  The 
lines  of  the  vessels  running  through  it  for  any  tortuosity  or  un- 
usual distinctness  from  congestion.  The  glomeruli  for  unusual 
prominence  and  alteration  of  colour  on  treatment  with  iodine. 

(2)  The  line  between  cortex  and  medulla,  which  should  be 
fairly  distinct,  forming  a  series  of  arches.      In  cases  of  inter- 
stitial nephritis  this  line  is  indistinct  and  irregular.     Note  also 
the  appearance  of  the  larger  vessels  (renal  arches)  running 
between  cortex  and  medulla. 

(3)  The  medulla  for  its  colour,  any  opaque  lines  indicating  de- 
posits of  urates,  the  presence  of  small  grey  nodules — fibromata. 

(4)  The   pelvis    for   thickening,   haemorrhage,    calculus    or 
exudate  indicating  inflammation. 

(5)  The    peripelvic   fat  for    its    relative  amount.      In  the 
normal  organ  there  is  only  a  very  small  amount  of  this.      In 
chronic  interstitial  nephritis,  on  the  other  hand,  where  there 
has  been  a  more  or  less  marked  shrinkage  of  the  organ,  it  is 
often  greatly  increased. 

(6)  With   a  pair  of  dissecting  forceps   take  hold  of  the 
capsule  of  the  organ,  ensuring  that  the  whole  capsule  is  grasped 
by  crushing  through  a  small  portion  of  the  most  superficial 
cortex  with  the  instrument.      Strip  the  capsule  from  the  cortex, 
noting  the  relative  ease  with  which  this  is  done,  i.e.  whether 
portions  of  cortex  are  removed  along  with  the  capsule.     Then 
note  the  appearance  of  the  outer  surface  of  the  organ,  whether 
it  is  smooth  or  rough.      If  rough,  whether  the  roughness  is 
uniform  or  irregular.      Look  for  subcapsular  cysts,  cicatrices 
indicating  old  infarcts  or  the  more  regular  markings  of  foetal 
lobulation.     Note  lastly  the  thickness  of  the  capsule. 


DISEASES  OF  THE  PELVIS  OF  THE  KIDNEY 

Hydronephrosis,  or  dilatation  of  the  pelvis  of  the  kidney, 
is  due  to  obstruction  to  the  outflow  of  the  urine.  The 
condition  may  be  bilateral  or  unilateral. 

(i)  Bilateral  hydronephrosis  is  due,  as  a  rule,  to  some 
obstruction  to  the  passage  of  urine  through  the  urethra, 
e.g.  stricture,  enlarged  prostate,  calculus  in  the  bladder. 

15 


226    DISEASES  OF  THE  KIDNEY  AND  BLADDER 

Occasionally  it  is  produced  by  a  large  tumour  in  the  pelvis 
pressing  upon  both  ureters.  The  ureters  in  this  type  are 
dilated  throughout  as  well  as  the  pelves. 

(2)  Unilateral  hydronephrosis  is  due  to  some  obstruction 
to  the  flow  of  urine  through  one  of  the  ureters.  This  may  be 
(a)  something  blocking  the  lumen  of  the  ureter,  usually  a 
calculus  ;  (b)  kinking  of  the  ureter  from  cicatricial  changes 
following  injury,  with  the  formation  often  of  one  or  more 
S-shaped  bends  (Fig.  91) ;  (c)  a  tumour  pressing  upon  the 
ureter  from  the  outside. 

As  the  result  of  the  increased  pressure  within  the  pelvis, 
the  calyces  become  distended  and  the  pyramids  flattened. 
Gradually  the  pressure  causes  atrophy  of  the  kidney  sub- 
stance, until  eventually  it  may  disappear  altogether,  leaving 
a  fibrous  bag  containing  a  fluid  which  shows  only  traces 
of  urea  and  urinary  salts.  This  distention  occurs  only  if 
the  obstruction  is  incomplete.  Complete  obstruction  to  the 
outflow  of  urine  leads,  not  to  hydronephrosis,  but  to  atrophy 
of  the  kidney. 

Pyonephrosis  is  a  precisely  similar  condition  to  the  pre- 
ceding, in  which  the  fluid  in  the  dilated  pelvis  is  pus.  In- 
fection may  occur  from  the  bladder  or  by  way  of  the  blood. 

Pyelitis,  or  inflammation  of  the  pelvis  of  the  kidney,  may 
be  associated  with  the  irritation  due  to  the  presence  of  a 
calculus.  More  often  it  is  caused  by  an  organism  such  as 
B.  coli  or  one  of  the  pyogenic  cocci.  Occasionally  it  may  be 
due  to  the  presence  of  animal  parasites  such  as  filarise.  In 
the  organismal  type,  infection  may  come  from  the  bladder 
or  from  the  kidney. 

In  many  cases  there  is  very  little  alteration.  In  well- 
marked  cases  there  is  congestion  of  the  vessels,  minute 
haemorrhages  and  exudate. 

The  inflammatory  process  tends  to  spread  to  the  kidney  it- 
self, giving  rise  to  suppurative  pyelonephritis  (surgical  kidney). 


DISEASES  OF  THE  URINARY  BLADDER     227 

Turbid  fluid  in  the  pelvis  of  the  kidney  should  be  examined 
microscopically  in  doubtful  cases,  as  phosphates  in  the  urine 
give  an  appearance  very  similar  to  that  of  pus. 

DISEASES  OF  THE  URINARY  BLADDER 

Inflammation  (Cystitis).  —  Organisms  may  reach  the 
bladder  (i)  from  the  blood,  often  by  way  of  the  kidney,  or 
(2)  from  without  by  the  urethra.  The  latter  is  the  commoner 
path  of  infection,  the  organisms  being  introduced  by  means 
of  a  catheter  or  finding  their  own  way  up  in  cases  where  there 
is  incontinence  of  urine.  The  commonest  germ  found  in 
cases  of  cystitis  is  B.  coli,  but  B.  proteus  and  cocci  of  various 
types  are  met  with.  Cystitis  may  also  be  associated  with 
inflammation  in  neighbouring  organs,  such  as  the  rectum. 
A  degree  of  inflammation  is  usually  present  along  with 
calculi^  but  the  calculus  may  be  a  sequel  of  cystitis. 

In  slight  degrees  of  the  disease  there  may  be  merely  an 
increased  vascularity  of  the  mucous  membrane  of  the  organ. 
In  more  severe  types  there  is  ulceration  and  in  some  cases 
necrosis  of  the  mucous  membrane  with  slough  formation. 

The  urine  in  cystitis  may  be  acid  when  voided,  but  it  tends 
rapidly  to  become  alkaline.  In  some  cases  this  change  occurs 
within  the  bladder.  There  is  usually  a  copious  deposit  con- 
sisting, in  addition  to  phosphates,  of  transitional  epithelial 
cells  from  the  bladder  wall,  pus  cells  and"  micro-organisms. 

Tuberculosis  of  the  bladder  is  usually  associated  with 
tuberculosis  of  the  kidney.  It  appears  first  as  small  tubercles 
under  the  mucous  membrane.  These  are  found  either 
grouped  thickly  round  the  orifices  of  the  ureters  (descending 
infection)  or  at  the  trigone  and  neck  of  the  bladder  (ascending 
infection).  Later,  ulceration  occurs,  due  to  coalescence  of 
the  small  tubercles  and  destruction  of  the  mucous  membrane. 
As  in  other  types  of  bladder  ulceration  urinary  salts  are 
frequently  deposited  upon  the  floor  of  the  ulcer. 


228    DISEASES  OF  THE  KIDNEY  AND  BLADDER 

Tumours. — The  common  tumours  of  the  bladder  are  the 
villous  papilloma  and  the  carcinoma. 

The  former  occurs  as  a  soft,  friable,  "  sea-anemone  "-like 
outgrowth,  usually  from  the  base  of  the  bladder.  Filaments 
from  the  growth  not  infrequently  break  away  and  are  found 
along  with  isolated  epithelial  cells  in  the  urine.  Haemorrhage 
is  very  common  in  such  cases.  Very  frequently  these 
papillomata  are  multiple. 

Carcinoma  of  the  bladder  is  usually  of  the  squamous 
epithelioma  type.  It  appears  as  an  ulcerated  area  with 
raised  hard  margins. 

Calculi  in  the  Urinary  Tract. — These  are  found  in 
the  pelvis  of  the  kidney  or  in  the  bladder,  also  occasionally 
in  process  of  passing  down  the  ureter  or  urethra.  Stones 
which  originate  in  the  pelvis  of  the  kidney  may  in  this  way 
be  found  in  the  bladder.  Urinary  calculi  are  rarely  found 
in  the  post-mortem  room.  They  are  usually  solitary,  but  may 
attain  a  very  large  size  and  may  show  branching  as  in  the  so- 
called  "  coralline  "  calculus  of  the  kidney  (Fig.  93). 

Those  which  form  hi  the  pelvis  of  the  kidney  are  usually 
composed  of  uric  acid,  urates  or  oxalate  of  lime,  or  a  combina- 
tion of  these  with  phosphates.  Those  which  arise  in  the 
bladder  are  usually  composed  of  phosphates. 

By  blocking  the  pelvis  of  the  kidney,  calculi  not  infre- 
quently cause  hydronephrosis.  The  presence  of  a  stone  in 
the  bladder  leads  to  hypertrophy  of  the  wall  of  the  viscus 
and  to  a  degree  of  cystitis. 

Parasites. — Bilharzia  hcematobia  is  sometimes  found  in 
the  bladder.  The  adult  worms  occur  in  the  vesical  veins. 
The  ova,  which  show  a  characteristic  terminal  spine,  are 
found  in  the  submucosa,  where  they  cause  thickenings  and 
papular  elevations.  They  also  occur  in  the  urine  along 
with  red  blood  corpuscles. 


CHAPTER  XI 

DISEASES   OF  THE  BRAIN  AND   SPINAL  CORD   AND 
THEIR   MEMBRANES 

INFLAMMATION  OF  THE  MEMBRANES  OF  THE 
BRAIN  (MENINGITIS) 

TYPES. 

1.  Pachy meningitis. 

(1)  Acute. 

(2)  Chronic. 

(3)  Pachymeningitis  haemorrhagica. 

2.  Leptomeningitis. 

(1)  Acute,  due  to  various  pyogenic  organisms. 

(2)  Tuberculous. 

(3)  Syphilitic. 

(4)  Serous. 

Two  main  types  of  this  may  be  distinguished,  although 
the  two  very  frequently  occur  together,  (i)  Pachymeningitis, 
or  inflammation  of  the  dura  mater.  (2)  Leptomeningitis,  or 
inflammation  of  the  pia-arachnoid. 

i,  Pachymeningitis,  or  inflammation  of  the  dura  mater, 
is  usually  secondary  to  suppurative  inflammation  in  one  of 
the  cavities  in  the  bone,  such  as  middle  ear  and  mastoid  disease, 
or  to  a  penetrating  wound  of  the  skull.  It  may  be  accompanied 
by  septic  thrombosis  in  the  venous  sinuses  in  the  neighbour- 
hood of  the  inflammatory  focus,  or  by  abscess  of  the  brain 

229 


230  DISEASES  OF  THE  BRAIN 

or  leptomeningitis.  The  membrane  is  somewhat  swollen, 
the  vessels  are  injected,  and  there  is  exudate  on  the  sur- 
face. The  pia-arachnoid  may  adhere  to  the  affected  area. 

Chronic  pachymeningitis  may  occur  in  connection  with 
fractures  or  with  chronic  bone  disease. 

A  rare  condition  known  as  pachymeningitis  hcemorrhagica 
is  sometimes  found  in  cases  of  insanity,  such  as  general 
paralysis  and  senile  dementia,  and  in  alcoholism  and  scurvy. 
On  the  inner  aspect  of  the  dura  mater  which  covers  the 
vertex,  as  a  rule  close  to  the  j 'ah  cerebri,  laminated  blood 
clot  is  found.  Some  regard  the  condition  as  being  merely  a 
haemorrhage  due  to  rupture  of  a  degenerated  vessel,  others 
consider  it  to  be  inflammatory.  Under  the  latter  supposition 
the  primary  change  is  believed  to  be  a  fibrinous  exudate  on 
the  surface  of  the  membrane.  This  becomes  organised. 
Some  of  the  young  blood-vessels  in  this  granulation  tissue 
give  way  from  time  to  time  and  so  layer  upon  layer  of  blood 
clot  is  formed.  Those  who  hold  the  view  that  the  condition 
is  purely  hsemorrhagic  see  in  the  granulation  tissue  merely 
an  attempt  to  organise  the  blood  clot. 

2.  Leptomeningitis,  or  inflammation  of  the  pia-arachnoid. 
— This  may  be  due  to  : — 

(1)  Infection   passing   from  a  fracture  or  a  penetrating 
wound  of  the  skull  or  from  a  fracture  of  the  base  by  way  of 
the  ear  or  nose. 

(2)  Spread  of  inflammation  through  the  bone  from  a  sup- 
purative  focus  in  middle  ear,  mastoid  antrum,  or  other  space. 

(3)  Infection  from  the  Blood. — In  cases  where  organisms 
are  circulating  in  the  blood  the  germs  may  settle  down  in  the 
membranes  of  the  brain,  because  for  some  reason  these  form 
a  favourable  site  for  their  growth. 

As  regards  the  organisms  found  :  inasmuch  as  pneumo- 
cocci  in  children  and  streptococci  in  adults  are  common 
causes  of  middle-ear  disease,  such  germs  are  very  frequently 


DISEASES  OF  THE  BRAIN  231 

found  either  by  themselves  or  in  combination  with  others. 
Staphylococci  and  B.  pyocyaneus  occasionally  occur.  B.  in- 
fluenza may  be  met  with  sometimes  as  a  bacillus  or  in  the  form 
of  filaments.  The  Diplococcus  intracellularis  meningitidis  is 
found  in  cases  of  epidemic  cerebro-spinal  meningitis  (spotted 
fever).  B.  tuberculosis  is  responsible  for  a  large  number  of 
cases.  Rarer  organisms  are  B.  anthracis  and  Streptothrix 
actinomyces.  In  tuberculous  meningitis,  and,  more  rarely, 
in  other  forms,  infection  may  be  due  to  spread  from  diseased 
vertebrae. 

Naked-eye  Appearances. — There  is  congestion  of  the  menin- 
geal  vessels,  and  vessels  normally  invisible  can  be  seen.  In 
some  cases  of  rapidly  fatal  cerebro-spinal  meningitis  this  is 
all  that  can  be  noted.  After  one  or  two  days  there  is  usually 
more  or  less  exudate.  This  exudate  may  be  fibrinous  or  puru- 
lent. It  may  be  very  obvious,  yellow  and  creamy,  or  thin 
and  inconspicuous.  It  tends  to  accumulate  in  the  spaces 
between  arachnoid  and  pia  (Fig.  94),  more  especially  in  the 
interpeduncular  space  and  in  the  sulci  along  the  lines  of  the 
vessels.  The  distribution  of  the  change  varies  in  different 
types.  In  most  types,  notably  in  cerebro-spinal  meningitis 
and  in  the  tuberculous  type,  the  condition  is  most  marked 
at  the  base,  the  exudate  occurring  in  the  interpeduncular 
space  and  spreading  up  on  either  side  along  the  Sylvian 
fissure,  also  on  to  the  surface  of  pons,  cerebellum  and  occipital 
lobes.  In  other  cases  the  change  is  most  marked  on  the 
vertex  or  over  the  frontal  lobes  (pneumococcal  cases).  The 
convolutions  tend  to  be  flattened.  There  is  usually  an  excess 
of  cerebro-spinal  fluid,  which  is  turbid  and  may  be  purulent. 
The  inflammatory  change  may  extend  to  the  ventricles, 
and  in  many  cases  these  spaces  show  more  or  less  distention 
with  fluid  (hydrocephalus). 

The  membranes  of  the  spinal  cord  are  very  constantly 
affected  to  a  greater  or  less  extent.  When  this  is  the  case 
the  term  cerebro-spinal  meningitis  may  be  applied. 


232  DISEASES  OF  THE  BRAIN 

Microscopic  Appearances. — These  are  similar  to  those  found 
in  inflammations  of  other  serous  surfaces.  There  is  dilatation 
of  blood-vessels,  exudation  of  fibrinous  material  on  the  surface 
and  in  the  substance  of  the  membranes,  and  emigration  of 
leucocytes,  chiefly  of  the  polymorphonuclear  type.  Organisms 
may  be  found  in  suitably  stained  specimens.  There  is  usually 
more  or  less  inflammation  of  the  underlying  cerebral  substance 
(encephalitis),  as  indicated  by  cellular  infiltration  around 
vessels  dipping  into  the  brain  substance. 

Microscopic  examination  of  the  cerebro-spinal  fluid  obtained 
during  life  by  lumbar  puncture  shows  polymorphonuclear 
leucocytes  in  greater  or  less  abundance,  and  sometimes  germs. 

Tuberculous  meningitis  requires  special  mention. 

It  is  essentially  a  basal  inflammation  and  is  usually 
associated  with  a  similar  inflammation  of  the  spinal  meninges. 
A  more  or  less  marked  increase  of  cerebro-spinal  fluid  is 
found,  which  is  often  fairly  clear.  In  the  sub -arachnoid 
space  at  the  base  of  the  brain  and  spreading  up  the  sylvian 
fissures  there  may  be  an  opalescent  exudate.  Sometimes 
it  is  conspicuous  and  creamy,  at  other  times  it  is  difficult  to 
make  out  at  all.  The  smaller  vessels  appear  thickened,  owing 
to  perivascular  infiltration,  and  at  the  spreading  margin, 
along  the  vessels  of  the  Sylvian  fissure,  or  upper  surface  of 
cerebellum,  etc.,  minute  grey  or  yellow  tubercles  are  found 
(Fig.  95).  Sometimes  these  are  only  discovered  on  stripping 
the  membranes  and  examining  them  most  carefully  by 
floating  them  out  in  water.  The  ventricles  are  more  or  less 
distended  with  fluid  which  may  be  clear  or  slightly  turbid. 

Microscopic  Appearances. — The  cells  in  the  exudate  tend 
to  be  of  the  mononuclear  type,  but  in  the  more  acute  cases 
polymorphs  are  often  abundant.  Here  and  there,  especially 
round  vessels,  are  follicular  aggregations  of  cells  with  giant 
cells  or  necrotic  centres.  Tubercle  bacilli  may  be  numerous, 
but  are  often  difficult  to  find. 

Microscopic  examination  of  the  fluid  obtained  by  lumbar 
puncture  shows  cells  which  tend  to  be  of  a  mononuclear  type, 


DISEASES  OF  THE  BRAIN  233 

but  polymorphs  are  not  infrequently  present  in  considerable 
numbers.  On  careful  search  tubercle  bacilli  are  generally  to 
be  found,  but  it  is  necessary,  in  most  cases,  to  centrifugalise 
the  fluid,  and  to  make  several  films  from  the  deposit. 

Syphilitic  Meningitis. — This  may  be  acute  associated 
with  an  infiltration  of  the  pia-arachnoid  with  small  round 
cells.  It  may  be  accompanied  by  gummata  in  the  shape  of 
small  foci  with  yellow  caseous  centres  which  show  a  tendency 
to  infiltrate  the  brain  substance.  Or  it  may  be  chronic, 
associated  with  fibrous  thickening  at  the  base  of  the  brain 
and  leading  to  compression  of  the  cranial  nerves. 

Serous  meningitis  is  a  condition  comparatively  recently 
recognised  which  is  characterised  by  congestion  and  oedema 
of  the  meninges  with  production .  of  a  serous  and  cellular 
exudate.  It  is  most  frequently  found  in  children  and  is 
associated  with  infective  diseases,  e.g.  measles  and  scarlet 
fever  ;  in  adults  it  is  sometimes  found  in  relation  to  alcoholism 
and  kidney  disease.  The  appearances  are  sometimes  more 
marked  at  the  base  of  the  brain,  sometimes  at  the  convexity. 
The  causal  factor  is  not  always  clear. 

DISEASES  OF  THE  BRAIN 

CIRCULATORY  CHANGES 

1.  Congestion  of  the  cerebral  vessels  may  be  due   to 
active  hypersemia  in  inflammations  such  as  lepto-meningitis 
or  to  chronic  venous  congestion,  the  result  of  valvular  disease 
of  the  heart. 

2.  Aneemia  may  be  part  of  a  general  want  of  blood,  as 
in  pernicious  or  other  type  of  anaemia  or  severe  haemorrhage, 
or  it  may  be  local,  due  to  accumulation  of  blood  elsewhere  or 
to  the  pressure  of  a  tumour. 

3.  (Edema  is  a  common  condition  which  may  occur  as 
part  of  a  more  general  dropsy  or  may  be  localised  to  the 


234  DISEASES  OF  THE  BRAIN 

cerebral  substance.  The  causes  are  those  of  oedema  in  general, 
such  as  renal  and  heart  disease.  Alcoholism  is  a  not  un- 
common cause.  Chronic  alcoholics  not  infrequently  die, 
apparently  from  this  cause  alone.  Clinically  such  cases  may 
simulate,  as  regards  their  symptoms,  many  different  types 
of  cerebral  lesion, — haemorrhage,  thrombosis,  etc. — and  at 
the  post-mortem  the  only  brain  condition  found  is  oedema. 

On  section  the  brain  in  cedema  has  a  moist  shiny  appearance. 
The  grey  matter  is  often  rather  more  obvious  than  usual  from 
congestion  of  minute  vessels.  A  small  amount  of  fluid  may 
be  squeezed  from  the  cerebral  substance,  and  the  ventricles 
are  usually  distended  with  fluid. 

4.  Hydrocephalus,  or  excess  of  fluid  in  the  lateral 
ventricles,  may  be  congenital  or  acquired. 

In  the  congenital  form  the  head  may  attain  an  enormous 
size.  The  cranial  bones  are  thinned  and  separated  from  one 
another.  There  is  great  distention  of  the  lateral  ventricles 
and  narrowing  of  the  cerebral  substance.  The  large  size  of 
the  head  leads  to  difficulty  at  parturition.  The  cause  of  the 
condition  is  obscure,  but  it  is  probably  mainly  due  to  obstruc- 
tion to  the  outflow  of  fluid  from  the  ventricles  into  the 
meningeal  spaces. 

Acquired  hydrocephalus  follows  sometimes  from  basal 
meningitis  or  tumour  formation  at  the  base  of  the  brain. 
It  is  due  to  the  matting  of  the  meninges  and  consequent 
obstruction  to  lymph -flow,  following  on  the  inflammatory 
condition  (Fig.  96),  or  to  direct  pressure  of  the  neoplasm  on 
the  vessels. 

Excess  of  cerebro-spinal  fluid  in  subdural  and  subarachnoid 
spaces  is  met  with  in  a  large  variety  of  diseases.  It  may  occur 
as  part  of  a  general  cedema ;  it  may  be  due  to  inflammation 
of  the  meninges ;  or  may  accompany  atrophy  of  the  cerebral 
substance  in  chronic  alcoholism  and  in  various  forms  of 
mental  disease. 


DISEASES  OF  THE  BRAIN  235 

5.  Arterial  Obstruction. — This  may  be  due  either  to 
thrombosis  or  embolism.  Thrombosis  is  usually  secondary  to 
disease  of  the  arterial  wall,  either  atheroma  or  syphilitic 
disease  (endarteritis  obliterans).  It  also  occurs  secondary  to 
embolism.  It  is  met  with  more  commonly  in  the  branches 
of  the  posterior  cerebral  and  basilar  arteries  and  in  the 
small  superficial  cortical  branches.  Embolism  is  brought 
about  by  the  impaction  of  an  embolus,  usually  a  portion  of 
a  thrombus,  in  a  vessel  the  lumen  of  which  is  too  small  for 
its  passage.  The  portion  of  thrombus  may  come  from  (i) 
a  vegetation  on  the  mitral  or  aortic  valve  ;  (2)  a  thrombus 
in  the  auricle  or  ventricle ;  (3)  a  thrombus  on  a  patch  of 
atheroma  in  the  ascending  aorta;  or  (4)  from  a  thrombus 
in  an  aneurysm  of  the  ascending  aorta  or  aortic  arch  (see 
diagram,  p.  62).  The  arteries  at  the  base  of  the  brain  are 
specially  apt  to  be  involved.  The  commonest  vessel  to  be 
blocked,  because  it  offers  the  most  direct  route  for  the  embolus, 
is  the  middle  cerebral  (usually  the  left)  or  its  branches.  Then, 
in  order  of  frequency,  come  the  posterior  cerebral,  the  verte- 
bral, the  anterior  cerebral,  the  cerebellar  and  basilar.  As 
a  result  of  the  presence  of  the  embolus  blocking  the  vessel, 
thrombosis  occurs  to  a  varying  extent. 

Results  of  Arterial  Obstruction. — The  cerebral  arteries, 
more  especially  those  branches  going  to  the  ganglia  at  the 
base  of  the  brain,  belong  to  the  group  of  "  end  arteries,"  i.e. 
arteries  whose  collateral  anastomosis  is  not  equal  to  the 
re-establishment  of  the  circulation  after  blocking  of  the  vessel. 
Infarction  therefore  occurs,  and  the  type  of  infarct  which 
develops  is  the  pale  infarct.  The  reason  for  this  is  that, 
owing  to  swelling  of  the  nerve  elements  in  the  primary 
stages  of  degeneration,  the  return  of  blood  by  way  of  minute 
collaterals  cannot  occur  or  occurs  only  to  a  very  small  extent. 
In  contrast  to  other  organs  such  as  kidney  and  spleen,  where 
pale  infarcts  also  occur,  the  necrotic  change  which  takes 
place  results  in  progressive  softening  (colliquative  necrosis), 


236  DISEASES  OF  THE  BRAIN 

instead  of,  as  in  kidney  and  spleen,  coagulation  necrosis. 
Such  a  pale,  softened  area  is  often  called  an  area  of  white 
softening.  Sometimes  there  is  a  certain  amount  of  return  of 
blood  which  escapes  from  the  degenerating  vessels  with 
resulting  numerous  small  haemorrhages  (red  softening).  Later 
on,  as  liquefaction  proceeds  and  changes  occur  in  the  blood- 
pigment,  the  area  tends  to  become  yellow  (yellow  softening). 
Ultimately,  removal  of  the  degenerated  material  occurs  with 
the  formation  of  a  cyst,  the  walls  and  sometimes  the  contents 
of  which  show  yellow  pigmentation  (Fig.  98). 

In  the  later  stages  such  areas  are,  of  course,  easily  recognised. 
Sometimes,  when  death  occurs  rapidly  owing  to  the  area 
involved  being  large  or  including  some  vital  centre,  the  recogni- 
tion is  somewhat  difficult.  There  may  be  nothing  more  than 
a  very  slight  softening  of  the  cerebral  substance.  Thus  in 
all  cases  where  arterial  obstruction  is  suspected  the  consistence 
of  the  brain  substance  should  be  estimated  by  careful  palpation  ; 
suspected  areas  being  compared  as  regards  their  consistence 
with  the  corresponding  areas  on  the  other  side  as  well  as  with 
surrounding  parts  of  the  brain. 

Microscopic  Appearances. — These  are  the  changes  usually 
found  in  degenerations  of  the  central  nervous  system  : — 

Ganglion  cells  show  loss  of  staining  of  their  Nissl  bodies 
and  nuclei.  The  nucleus  loses  its  central  position  and  is  eventu- 
ally extruded.  The  cell  processes  become  fragmented. 

Myelin  substance  absorbs  water,  swells  and  breaks  up  into 
fatty  material,  which  may  be  demonstrated  by  fat  stains, 
cholesterin,  lecithin,  etc.  The  fat  globules  are  taken  up  to  a 
certain  extent  by  phagocytes,  thus  forming  granular-looking 
cells  sometimes  called  compound  granular  corpuscles. 

In  the  later  stages  the  neuroglia  and  other  connective 
tissue  elements  proliferate,  the  young  mononuclear  cells  which 
are  thus  produced  acting  as  phagocytes  for  fat,  blood  corpuscles 
and  blood  pigment.  The  area  is  invaded  by  leucocytes,  mainly 
mononuclear,  which  also  act  as  phagocytes.  Haematoidin 
crystals  are  often  found  at  the  margin  of  the  area,  also  in  the 
fluid  contents  of  the  cysts. 


DISEASES  OF  THE  BRAIN  237 

6.  Cerebral  Haemorrhage. — Although  capable  of  con- 
siderable resistance  to  strain,  the  arteries  of  the  brain  are 
much  thinner- walled  than  those  of  any  other  organ  or  part. 
More  especially  are  they  deficient  as  regards  muscular  sub- 
stance. Moreover,  they  are  less  well  supported  owing  to 
the  relative  softness  of  the  brain  substance.  For  these 
reasons,  rupture  of  vessels  and  consequent  haemorrhage  is 
more  common  in  the  brain  than  in  any  other  organ. 

There  are  two  main  factors  operative  in  cerebral  haemor- 
rhage : — (i)  degenerative  changes  in  the  vessel  wall ;  (2)  increased 
blood  pressure.  As  regards  the  degenerative  changes,  these 
may  be  relatively  acute  as  in  the  vessels  of  an  infarcted  area 
or  in  the  inflammation  following  septic  embolism  (e.g.  in 
ulcerative  endocarditis),  or  slowly  progressive  as  in  atheroma 
or  syphilitic  disease.  Not  infrequently  the  vessel,  previous 
to  rupture,  undergoes  localised  dilatation  with  the  formation 
of  an  aneurysm.  Increased  blood  pressure  is  either  sudden 
from  strain,  or  chronic,  as  met  with  in  cases  of  generalised 
thickening  of  the  vessels  and  in  kidney  disease,  which  is  so 
frequently  accompanied  by  chronic  vascular  disease.  Thus 
the  two  factors  often  occur  together,  and  in  all  cases  of 
cerebral  hemorrhage  careful  examination  of  the  vascular 
system  and  of  the  kidneys  should  be  made. 

Types. 

1.  Small  capillary  (petechial)  haemorrhages. 

2.  Large  haemorrhages  which  may  be  into 

(a)  Basal  ganglia  sometimes  extending  into  the 

lateral  ventricle. 

(b)  Pons  Varolii. 

(c)  Pia-arachnoid  on  cerebral  cortex. 

(d)  Cerebellum. 

(e)  Other  parts  of  the  brain. 

3.  Haemorrhage  due  to  laceration  of  brain. 

As  regards  haemorrhage  caused  by  disease,  one  may  dis- 
tinguish, (i)  small  capillary  hemorrhages ,  which  are  found  in 


238  DISEASES  OF  THE  BRAIN 

acute  inflammation  of  the  cerebral  substance,  infective 
diseases,  cerebral  softenings,  blood  diseases  such  as  purpura 
and  pernicious  anaemia,  or  in  tumours  ;  (2)  large,  extensive 
hcemorrhages ,  which  are  usually  due  to  chronic  disease  of 
the  vessels,  much  less  frequently  due  to  septic  embolism 
in  cases  of  acute  (usually  ulcerative)  endocarditis,  and  may 
occasionally  be  due  to  rupture  of  a  vessel  in  a  tumour  such 
as  a  glioma.  The  first  type  of  cause  is  met  with  most  commonly 
in  individuals  past  the  prime  of  life,  the  second  and  third 
types  may  be  met  with  at  any  age.  It  is  stated  that  in 
something  like  one-third  to  a  half  of  the  cases  of  the  first  type 
the  point  of  actual  rupture  is  a  small  aneurysm.  Some  of 
these  aneurysms,  more  especially  those  in  the  vessels  at  the 
base  of  the  brain,  are  easily  visible  with  the  naked-eye. 
Others,  which  are  usually  in  connection  with  the  more  minute 
vessels  inside  the  cerebral  substance,  are  only  visible  under  a 
low  power  of  the  microscope.  Such  aneurysms  have  been 
called  miliary.  Some  of  these  miliary  aneurysms  are  in 
reality  false  aneurysms. 

The  most  common  site  for  cerebral  haemorrhage  is  the 
region  of  the  basal  ganglia  (Fig.  97).  Something  like  75  per 
cent  of  cases  occur  in  this  position.  The  vessel  which  ruptures 
is  usually  the  lenticulo-striate  branch  of  the  middle  cerebral 
artery,  which  supplies  the  outer  segment  of  the  lenticular 
nucleus  and  the  external  capsule.  It  then  perforates  the 
internal  capsule  and  ends  in  the  caudate  nucleus.  So  fre- 
quently is  this  vessel  the  site  of  origin  of  the  haemorrhage 
that  it  has  been  called  the  artery  of  cerebral  haemorrhage. 

The  next  most  frequent  site  for  haemorrhage  is  the  pons 
Varolii  (12  per  cent)  (Fig.  100).  In  something  like  12  per 
cent  the  haemorrhage  commences  in  one  of  the  superficial 
vessels,  i.e.  one  of  the  cerebral  arteries  which  has  not 
yet  penetrated  the  brain  substance.  A  rare  situation  for 
haemorrhage  is  the  cerebellum  and  other  parts  of  the  cerebrum, 
such  as  the  frontal  lobe.  When  the  cause  of  the  haemorrhage 


DISEASES  OF  THE  BRAIN  239 

is  a  septic  embolus  or  one  of  the  haemorrhagic  diseases  such 
as  purpura,  the  site  may  be  almost  anywhere,  e.g.  the  frontal 
lobe.  In  the  case  of  a  haemorrhage  into  the  basal  ganglia 
or  internal  capsule,  if  there  is  much  tearing  up  of  the  brain 
substance  the  blood  may  escape  into  the  lateral  ventricles  and 
from  there  extend  under  the  pia-arachnoid.  Haemorrhage 
under  the  pia  mater  is  also  observed  when  the  ruptured 
vessel  is  outside  the  brain  substance. 

Naked-eye  Appearances. — On  removing  the  skull  cap  and 
reflecting  the  dura  mater,  a  general  flattening  of  the  convolu- 
tions is  usually  observed.  Sometimes  the  flattening  is  more 
marked  on  one  side  (the  side  of  the  haemorrhage)  than  the 
other.  In  the  case  of  haemorrhage  into  the  lateral  ventricles, 
or  haemorrhage  from  one  of  the  larger  vessels  before  it  enters 
the  brain  substance,  or  from  an  aneurysm  of  a  large  vessel, 
extravasated  blood  may  be  seen  in  the  subarachnoid  space 
sometimes  extending  on  to  the  vertex,  but  usually  more 
marked  at  the  base  of  the  brain. 

On  section  of  the  brain,  a  larger  or  smaller  area  of  cerebral 
substance  is  found  torn  up  and  the  space  occupied  by  blood 
clot.  In  older  haemorrhages  the  clot  becomes  brownish  in 
colour,  and  the  surrounding  tissue  is  stained  yellow. 

In  all  cases  of  cerebral  haemorrhage,  as  already  stated, 
careful  examination  should  be  made  of  the  vascular  system — 
vessels  and  heart — and  of  the  kidneys.  The  vessels  as  a 
rule  show  more  or  less  marked  arterio-sclerosis,  the  heart 
shows  hypertrophy  of  the  left  ventricle  and  in  some  rare 
cases  acute  endocarditis.  The  kidneys  very  constantly  show 
more  or  less  marked  chronic  interstitial  nephritis,  which  may 
be  of  the  arterio-sclerotic  type. 

Following  on  a  haemorrhage  there  is  always,  if  the  patient 
survive,  more  or  less  secondary  degenerative  change  in  the 
nerve  tracts  which  have  been  interrupted.  Thus  when  the 
haemorrhage  occurs  into  one  internal  capsule  there  will  be 
descending  degeneration  in  the  direct  pyramidal  tract  of  the 


240  DISEASES  OF  THE  BRAIN 

same  side  and  in  the  crossed  pyramidal  tract  of  the  opposite 
side  in  the  spinal  cord. 

Superficial  haemorrhage  may  also  be  caused  by  laceration 
of  the  brain  substance  due  to  injury.  If  the  patient  survive 
some  time,  red  or  yellow  softening  occurs  (see  p.  236). 

Microscopically,  there  is  little  to  be  seen  beyond  the 
extravasation  of  red  blood-cells.  In  older  haemorrhages  there 
is  more  or  less  pigmentation  from  deposit  of  hasmatoidin  in 
the  parts  around.  There  tends  also  to  be  an  increase  of 
connective  tissue  (neuroglia  and  fibrous  tissue)  around  the  clot. 


INFLAMMATION  OF  THE  BRAIN  (ENCEPHALITIS) 

In  the  brain  substance  subjacent  to  inflamed  meninges, 
in  the  neighbourhood  of  injuries,  blood  clots,  areas  of  softening 
and  tumours  there  is  always  more  or  less  marked  inflammatory 
change,  showing  itself  in  degenerative  changes  in  the  ganglion 
cells  and  nerve  processes,  proliferation  of  neuroglia,  infiltra- 
tion with  mononuclear  cells,  particularly  around  vessels. 

Types. 

1.  Simple  encephalitis  following  injuries,  etc.  (see  above). 

2.  Suppurative  encephalitis  (abscess). 

(d)  Pyaemic  type. 
(b)  Solitary  abscess. 

3.  Tuberculosis. 

4.  Syphilis. 

Suppurative  Encephalitis  (Cerebral  Abscess).  —  Two 
types  may  be  distinguished  :  (i)  Pycemic,  (2)  Solitary. 

The  pycemic  type  is  usually  minute,  and  consists  of 
numerous  abscesses  scattered  irregularly  through  the  brain 
substance.  There  is  usually  haemorrhage  around  the 
abscesses  owing  to  the  vessels  damaged  by  the  inflammatory 
process  giving  way. 

The  solitary  abscess  is  commonly  due  to  extension  of 
inflammation  from  neighbouring  parts,  as  a  rule  to  middle 


DISEASES  OF  THE  BRAIN  241 

ear  disease  (suppurative  otitis  media)  or  suppuration  in  the 
mastoid  antrum.  Thus  the  common  sites  of  abscess  of  the 
brain  are  the  temporo-sphenoidal  lobe  (Fig.  99)  and  the  cere- 
bellum, the  two  portions  of  the  brain  nearest  to  this  sup- 
purative focus.  Occasionally  such  abscesses  are  due  to 
injuries.  The  size  of  the  abscess  varies  much.  It  may  be 
the  size  of  a  walnut  or  even  a  tangerine  orange.  The  wall 
may  be  formed  of  softened,  ragged  cerebral  tissue,  or  of  a 
layer  of  granulation  tissue,  depending  upon  the  age  of  the 
abscess.  The  contents  consist  of  pus,  which  may  be  white, 
yellow  or  greenish,  and  is  often  very  foul -smelling.  The 
organisms  found  are  many  and  various — streptococci)  staphy- 
lococci,  B.  pyocyaneus,  etc. 

There  is  a  rare  and  unexplained  association  between 
solitary  abscess  of  the  brain  and  pulmonary  diseases  such  as 
bronchiectasis  and  empyema, 

Microscopically,  the  appearances  are  those  usually  seen 
in  abscess  formations — accumulations  of  polymorphonuclear 
leucocytes  with  necrotic  debris  and  germs  of  various  kinds. 
In  the  brain  substance  around  are  seen  haemorrhages,  infiltra- 
tion of  the  cerebral  substance  with  'inflammatory  cells  of 
various  types,  particularly  round  the  vessels,  and  degenerative 
changes  in  the  ganglion  cells  and  other  nerve  elements. 

Tuberculosis. — Miliary  tuberculosis ,  when  it  occurs  in  the 
brain,  shows  a  more  marked  tendency  to  affect  the  meninges 
than  the  cerebral  substance.  In  tuberculous  meningitis, 
however,  there  is  always  a  tendency  for  the  inflammatory 
change  to  pass  downwards  into  the  brain  substance.  Occasion- 
ally one  meets  with  multiple  caseous  foci  in  the  brain  substance, 
but  a  more  common  manifestation  is  the  solitary  nodule  which 
is  found  specially  in  relation  to  the  cerebellum  and  more 
commonly  in  children.  Such  nodules  often  act  like  tumours, 
producing  pressure  symptoms. 

Syphilis,  like  tuberculosis,  when  it  occurs  in  the  brain, 
shows  a  tendency  to  affect  the  meninges  and  vessels.  In  the 

16 


242  DISEASES  OF  THE  BRAIN 

latter  case,  periarteritis  and  endarteritis  are  not  uncommon. 
Occasionally,  gummata  are  met  with,  which,  like  the  solitary 
tubercle  nodules,  act  as  tumour  formations.  Such  gummata 
consist  of  a  caseous  centre  with  surrounding  granulation 
tissue. 

General  Paralysis. — This  is  a  disease  which  is  found 
chiefly  in  males,  between  the  ages  of  thirty  and  fifty.  Like 
locomotor  ataxia,  it  has  a  very  close  relationship  to  syphilis  ; 
in  fact,  quite  recently,  spirochsetes  have  been  found  in  the 
brain  in  cases  of  general  paralysis. 

If  death  occur  during  the  early  stages,  little  more  than 
swelling  and  congestion  of  the  brain  substance  is  found.  In 
the  later,  paralytic  stages  there  is  found  thickening  of  the 
membranes  of  the  brain,  which  are  very  adherent  to  the 
cerebral  substance.  Sometimes  pachymeningitis  hsemor- 
rhagica  (see  p.  230)  is  present.  There  is  a  general  atrophy  of 
the  brain  substance.  On  section,  oedema  of  the  cerebral 
tissue  is  often  found,  the  lateral  ventricles  are  dilated  and 
their  ependyma  shows  minute  granulations.  In  advanced 
cases  the  calvarium  is  usually  more  or  less  thickened  and 
condensed. 

Microscopically,  there  are  found  degenerative  changes  in 
the  ganglion  cells  and  wasting  of  their  dendritic  processes, 
proliferation  of  neuroglia,  thickening  of  the  blood-vessels,  and 
infiltration  of  the  perivascular  lymph  sheath  with  lymphocyte- 
like  cells. 

TUMOURS 

The  brain  substance  is  formed  of  (i)  nerve  cells  and 
their  processes,  which  are  epiblastic  in  origin  and  prac- 
tically never  give  rise  to  tumour  formations ;  (2)  neuroglia 
or  binding  connective  tissue  of  the  brain,  also  epiblastic  in 
origin,  which  is  the  source  of  a  majority  of  the  primary  growths 
of  the  brain;  (3)  vessels,  endothelium  of  meninges  and 
ordinary  connective  tissue,  mesoblastic  in  origin,  which  may 


DISEASES  OF  THE  BRAIN  243 

be  the  origin  of  sarcomata  and  angiosarcomata ;  (4)  the 
ependyma  lining  the  ventricles  from  which  carcinomatous 
tumours  may  arise. 
Types. 

A.  Primary  Tumours. 

1.  Gliomata. 

2.  Sarcomata,    endotheliomata,    angiosarcomata, 

psammomata,  etc. 

3.  Carcinomata. 

4.  Cholesteatomata. 

B.  Secondary  Tumours. 

1.  Granulomata. 

(a)  Tuberculous  nodules. 

(b)  Gummata. 

2.  Sarcomata. 

3.  Carcinomata. 

Primary  Tumours  of  the  Brain. — The  commonest  of  these 
is  the  glioma.  This  may  occur  in  any  part  of  the  brain. 
The  tumour  varies  in  size,  and  has  a  grey,  pink  or  white 
appearance,  and  is  not  well  defined.  Sometimes  it  is 
translucent,  at  other  times  opaque.  Haemorrhages  fre- 
quently occur  in  it.  The  tumour  may  be  simple,  but 
often  is  malignant,  and  is  then  called  glw-sarcoma. 

Microscopically,  the  simple  type  shows  branching  cells 
with  small  round  nuclei  and  long  "  spider-leg"  processes  which 
interlace  with  one  another,  forming  a  felted  network  between 
the  cells.  In  the  malignant  types  the  cells  are  more  numerous, 
larger  and  more  irregular,  and  the  intercellular  material  is 
correspondingly  reduced  in  amount. 

Other  forms  of  sarcomata  found  in  the  brain  are  angio- 
sarcomata, characterised  by  marked  vascularity  and  tendency 
to  haemorrhage ;  endotheliomata ,  with  the  sub  -  variety 
psammoma,  which  occur  mainly  in  connection  with  the 
meninges  (see  pp.  292-93). 


244  DISEASES  OF  THE  SPINAL  CORD 

As  already  mentioned,  primary  carcinomata  are  occasion- 
ally met  in  the  brain,  arising  from  the  ependyma  of  the 
ventricles. 

A  curious  and  rare  but  interesting  tumour  is  the  chole- 
steatoma  (Fig.  101),  also  known  as  the  "  pearl  "  tumour  from 
the  mother-of-pearl  appearance  of  the  surface.  It  is  a  solitary 
tumour,  well  defined  from  the  brain  substance,  occurring  in 
connection  with  the  meninges  chiefly  towards  the  middle 
line.  On  section  it  is  soft  and  has  a  white,  laminated  appear- 
ance. On  microscopic  examination  it  shows  layers  of  what 
appear  to  be  epithelial  cells,  with  a  small  amount  of  subjacent 
connective  tissue  and  a  large  amount  of  laminated  dead 
epithelium.  Some  regard  the  tumour  as  arising  from  the 
pia  mater,  and  therefore  as  being  an  endothelioma  ;  others 
consider  it  to  be  formed  of  skin  epithelium  and  therefore  a 
teratoma. 

Secondary  tumours  are  relatively  common  in  the  brain. 
Both  sarcomata  and  carcinomata  are  met  with.  The  growths 
may  be  single  and  large  or  numerous  and  small. 

Under  this  heading  may  be  included  the  so-called 
"  granulomata "  or  nodules  composed  of  chronic  inflam- 
matory tissue  usually  with  caseous  centres,  and  either 
tuberculous  or  syphilitic  in  origin.  In  no  other  part  of  the 
body  are  such  nodules  regarded  as  tumours.  In  the  brain, 
however,  not  only  because  of  their  appearance  but  also  on 
account  of  the  effects  which  they  produce,  the  term  tumour 
may  be  applied  to  them. 

DISEASES  OF  THE  SPINAL  COED 

CONGENITAL  ABNORMALITIES 

Spina  Bifida. — This  is  a  congenital  malformation  due  to 
incomplete  closure  of  the  coverings  of  the  spinal  cord,  as  a 
rule,  in  its  lower  part.  Various  degrees  of  the  condition  are 
met  with,  from  one  where  the  only  superficial  indication  of 


DISEASES  OF  THE  SPINAL  CORD  245 

the  presence  of  an  abnormality  is  a  tuft  of  hair  over  the  lower 
lumbar  region  (spina  bifida  occulta)  to  one  where  skin  in 
addition  to  the  posterior  bony  wall  of  the  spinal  canal  is  absent. 
The  common  type  is  one  where  there  is  incomplete  closure  of 
the  bony  canal  posteriorly  associated  with  a  tumour  in  the 
lumbar  region  which  may  contain  meninges  only  (meningocele), 
or  nerve  elements  in  addition  to  meninges  (meningo-myelocele). 
Cases  of  spina  bifida,  if  at  all  marked,  do  not  live  long.  Infec- 
tion occurs  sooner  or  later  through  the  skin  and  spinal 
meningitis  results. 

Syringomyelia  is  a  rare  condition  of  the  spinal  cord  in 
which  there  is  a  tumour -like  overgrowth  of  the  neuroglia 
(gliosis)  in  or  near  the  centre  of  the  cord.  The  overgrowth 
is  in  a  longitudinal  direction  and  is  found  in  the  cervical, 
sometimes  in  the  cervical  and  dorsal  regions  of  the  cord. 
Usually,  either  throughout  the  affected  part  or  in  some  portions 
of  it,  there  is  a  cavity  in  the  centre  of  the  area  of  gliosis. 
This  condition  of  gliosis  associated  with  cavitation  is  known 
as  syringomyelia.  The  cavity  is  larger  than  and  distinct 
from  the  central  canal.  The  proper  nerve  structures  of  the 
cord  are  atrophied  in  consequence  of  the  pressure  of  this 
mass  of  connective  tissue.  In  outward  appearance  the  cord 
may  be  unaltered  or  may  be  enlarged. 

Microscopically,  in  the  affected  area  tissue  consisting 
entirely  of  neuroglia  is  found.  In  this  tissue  there  is  a  space 
or  cavity  which  may  or  may  not  be  lined  with  epithelium. 

Hydromyelia. — This  is  a  condition  corresponding  to  hydro- 
cephalus,  in  which  there  is  an  over-distention  of  the  central 
canal  with  fluid. 

INFLAMMATION  OF  THE  MEMBRANES  OF  THE 

CORD  (SPINAL  MENINGITIS) 

As  in  the  case  of  the  brain,  two  primary  types  may  be 
distinguished:  (i)  pachymeningitis  or  inflammation  of  the 


246  DISEASES  OF  THE  SPINAL  CORD 

dura  mater;  (2)  leptomeningitis  or  inflammation  of  the 
pia-arachnoid.  It  is  unnecessary  to  discuss  the  causation 
and  the  various  forms  of  the  condition,  as  these  have  already 
been  considered  under  cerebral  meningitis.  The  two  con- 
ditions are  commonly  combined,  the  term  cerebro-spinal 
meningitis  being  employed.  Sometimes  the  inflammatory 
change  commences  in  the  brain  and  spreads  secondarily  to 
the  cord ;  at  other  times  the  reverse  is  the  case.  In  addition 
to  spread  from  the  brain,  infection  may  reach  the  spinal 
meninges  from  an  inflammatory  focus  in  one  of  the  vertebrae, 
from  the  blood  or  from  the  skin  surface  in  cases  of  spina 
bifida  and  bed  sores. 


INFLAMMATION  OF  THE  CORD  (MYELITIS) 

Under  this  heading  are  included  a  number  of  conditions  of 
very  various  origin.  Myelitis  may  be  due  to  the  action  of 
irritants  and  organisms,  or  it  may  be  due  merely  to  pressure 
or  alterations  of  circulation.  The  causes  may  be  classified  as 
follows  :  (i)  Extension  of  inflammation  from  vertebrae  or 
meninges.  (2)  Organisms  and  toxins  brought  by  the  blood  stream, 
such  as  the  viruses  of  tetanus,  hydrophobia,  influenza,  acute 
poliomyelitis,  etc.  (3)  Pressure  of  dislocated  vertebra  or  tumour. 
(4)  Circulatory  disturbances — thrombosis  in  sunstroke,  embolism 
in  "  Caisson  "  disease.  Probably  under  this  heading  may 
also  be  included  the  cases  due  to  "  chill." 

As  regards  the  distribution  of  the  change,  the  part  involved 
may  be  mainly  the  grey  matter,  when  the  name  poliomyelitis 
has  been  applied.  Or  it  may  be  that  the  white  matter  is 
chiefly  affected.  As  a  rule,  both  are  implicated.  When  the 
whole  diameter  of  a  section  of  cord  is  affected,  the  term 
transverse  myelitis  is  used.  If  the  change  is  irregularly 
scattered  up  and  down  the  cord,  the  term  disseminated  is 
employed. 

The  morbid  anatomy  of  the  condition  varies  according  to 


DISEASES  OF  THE  SPINAL  CORD  247 

the  rapidity  of  the  change  and  the  stage  at  which  it  is  observed. 
In  the  early  stages  all  types  are  characterised  by  a  softening 
of  the  cord  substance.  In  testing  for  the  presence  of  the 
condition,  the  finger  should  be  gently  passed  down  the  cord 
and  any  alteration  in  consistence  noted. 

On  section  of  the  cord,  in  addition  to  the  softening,  there 
may  be  increased  vascularity,  which  gives  a  pink  appearance 
to  the  grey  matter  more  especially.  Sometimes  small 
hcemorrhages  are  present,  and  occasionally  the  cord  is  so 
softened  that  the  line  of  demarcation  between  grey  and  white 
matter  is  rendered  indistinct. 

The  later  stages  are  accompanied  by  an  overgrowth  of 
neuroglia  replacing  the  degenerated  nerve  elements.  This 
may  manifest  itself  by  atrophy  and  contraction  and  by  the 
appearance  of  grey  translucent  areas  with  variable  distribu- 
tion, a  condition  often  characterised  by  the  term  sclerosis. 
Degenerative  changes  occur  in  the  tracts  running  upwards 
and  downwards  from  the  area  or  areas  involved. 

Microscopic  changes. — These  are  similar  to  those  found  in 
encephalitis. 

(i.)  Changes  in  the  nerve  cells. — These  consist  in  a 
disappearance  of  the  Nissl  spindles,  loss  of  staining  capacity 
in  the  nuclei  with  margination  and  eventual  extrusion. 

(ii.)  Changes  in  the  processes  of  the  cells. — Swelling,  bead- 
ing and  fragmentation  of  axis  cylinders  and  other  processes. 
Degenerative  changes  in  the  myelin  sheath  associated  with 
setting  free  of  fat  in  a  demonstrable  form. 

(iii.)  Changes  in  the  neuroglia. — Swelling  and  proliferation 
of  the  cells,  many  of  which  become  free  and  act  as  phagocytes 
taking  up  fat  globules  and  appearing  as  large  vacuolated  cells 
(compound  granular  corpuscles).  In  the  later  stages  the 
proliferated  glia  cells  settle  down  to  form  more  or  less  extensive 
areas  of  gliosis,  replacing  the  nerve  elements. 

(iv.)  Vascular  changes. — Haemorrhage  or  thrombosis  may 
be  met  with.  Exudation  of  fluid  and  of  leucocytes  occurs  to 
a  greater  or  less  marked  extent,  depending  upon  the  acuteness 
of  the  inflammatory  change.  A  very  constant  appearance  is 


248  DISEASES  OF  THE  SPINAL  CORD 

a  filling  of  the  lymph  space  which  surrounds  the  vessels  of 
the  cord  (perivascular  lymph  space)  with  cells  which  may 
be  polymorphonuclear  leucocytes,  lymphocytes  or  vacuolated 
phagocytic  cells  of  uncertain  origin,  according  to  the  type  and 
the  acuteness  of  the  change. 

In  the  areas  of  secondary  degeneration  above  and  below  the 
level  of  the  lesion  there  is  disappearance  of  the  nerve  elements 
— axis  cylinders  and  myelin  sheaths — and  a  replacement  of 
these  by  an  overgrowth  of  neuroglia. 


DISEASES  OF  THE  SPINAL  CORD  TO  WHICH 
SPECIAL  NAMES  ARE  GIVEN 

There  is  a  number  of  diseases  which  affect  mainly  the 
spinal  cord  to  which  special  names  are  given.  Some  of  these 
are  inflammatory  in  orgin,  due  to  the  action  of  poisons  upon 
cells  and  their  processes,  others  are  degenerative.  No  hard 
and  fast  line  can  be  drawn  between  these  two  sets  of  causes, 
however.  No  system  of  classification  is  attempted,  because 
in  many  cases  the  site  of  the  primary  change,  whether  in  nerve 
cell,  nerve  process  or  nerve  ending,  is  uncertain.  Only  the 
more  important  conditions  are  included. 

Acute  Poliomyelitis.  —  This  condition  was  originally 
known  as  acute  anterior  poliomyelitis  and,  in  its  later  stages, 
as  infantile  paralysis.  At  first  thought  to  be  circulatory  in 
origin,  due  to  blocking  of  the  anterior  spinal  artery  by  embolus 
or  thrombus,  it  is  now  regarded  as  organismal  in  nature, 
due  to  a  specific  virus  the  exact  nature  of  which  has  not  yet 
been  shown.  The  virus  passes  through  a  porcelain  filter  and 
is  infectious  for  monkeys.  The  disease  may  be  epidemic  or 
sporadic.  It  occurs  mainly  in  young  children,  usually  in  the 
late  summer  and  autumn  months.  It  is  associated  with  more 
or  less  marked  fever,  and  later  on  with  the  development  of 
paralysis  in  muscles. 

The   condition  may  be  met  by  the   pathologist   in  the 


DISEASES  OF  THE  SPINAL  CORD  249 

early,  acute  stage,  or  in  the  later  stage,  when  there  is  atrophy 
arid  contracture  of  limbs. 

In  the  early  stage  the  condition  has  the  appearance  of 
a  myelitis  affecting  the  whole  of  the  substance  of  the  cord, 
not  merely  the  grey  matter,  although  the  change  may  be 
most  intense  in  the  latter.  As  regards  distribution  the 
change  may  be  met  with  in  the  cervical  or  lumbar  portions  of 
the  cord.  Usually  there  are  alterations  to  be  found  throughout 
the  cord,  sometimes  also  in  the  medulla  and  cerebrum.  The 
site  of  the  most  intense  change  may  or  may  not  show  softening. 
Sometimes  there  is  a  slight  degree  of  inflammation  of  the 
rneninges.  On  section  of  the  cord  there  is  usually  congestion 
of  the  grey  matter,  and  sometimes  there  are  scattered  haemor- 
rhages. 

Microscopically,  all  the  changes  described  in  connection 
with  myelitis  may  be  met  with.  There  are  degenerative 
changes  in  the  anterior  horn  cells,  infiltration  of  the  grey 
matter  with  cells,  partly  leucocytes,  more  especially  lympho- 
cytes, partly  multiplied  neuroglia  and  connective  tissue  cells. 
Small  haemorrhages  may  be  present.  Degenerative  changes 
may  also  be  found  in  the  white  matter,  but  the  most  obvious 
change  is  an  infiltration  of  the  perivascular  lymph  sheath  of 
the  vessels  with  cells,  chiefly  lymphocytes.  There  is  usually 
a  varying  amount  of  inflammatory  change  in  the  rneninges. 

The  later  stage  of  the  disease  is  connected  pathologically 
with  atrophy  of  the  grey  matter,  more  especially  of  the 
anterior  horn,  sometimes  unilateral,  at  other  times  bilateral. 
This  shrinkage  is  associated  microscopically  with  a  disappear- 
ance of  the  nerve  elements  and  overgrowth  of  neuroglia. 
There  is  also  present  a  descending  degeneration  in  the  motor 
tracts  and  nerves. 

Progressive  Muscular  Atrophy  (chronic  anterior  polio- 
myelitis).— This  is  a  condition  which  develops  in  middle  life, 
usually  in  males.  Overstrain,  injury,  exposure  to  severe  cold 
and  infective  disease  have  been  put  down  as  causes.  It  is 


250  DISEASES  OF  THE  SPINAL  CORD 

characterised  by  a  progressive  atrophy  of  the  muscles, 
usually  beginning  in  hand  and  arm,  especially  the  right  hand. 

The  primary  pathological  change  is  a  degeneration  with 
atrophy  in  the  anterior  horn  cells  of  the  grey  matter  in  the 
lower  cervical  region. 

In  the  disease  known  as  amyotrophic  lateral  sclerosis,  which 
is  believed  by  many  to  be  the  same  condition,  in  addition  to 
the  degenerative  change  in  the  motor  cells,  there  is  sclerosis 
in  the  crossed  pyramidal  tracts. 

Disseminated  or  Insular  Sclerosis. — This  is  a  disease 
which  usually  commences  in  early  adult  life.  Nothing 
definite  is  known  as  regards  its  etiology,  although  in  some 
cases  an  association  with  acute  infective  disease  has  been 
established.  It  is  characterised  clinically  by  (i)  a  spastic 
condition  of  the  limbs  associated  with  weakness ;  (2)  tremors ; 
(3)  alterations  of  speech  ;  (4)  nystagmus. 

As  regards  the  pathological  anatomy,  the  lesions  are 
usually  found  in  the  spinal  cord,  less  frequently  in  brain, 
pons  and  medulla,  and  consist  in  scattered,  grey,  transparent 
areas  of  sclerosis,  varying  much  in  size  and  shape,  and  having 
no  relation  to  any  structures  or  tracts  of  nerves. 

The  patches  occur  in  grey  and  white  matter  alike  and  are 
sharply  defined  from  the  surrounding  healthy  tissue.  As  a 
rule,  ascending  and  descending  degenerations  are  absent. 

Microscopically,  in  the  sclerosed  areas  the  medullary  sheath 
is  found  to  have  disappeared  entirely,  although  sometimes  the 
axis  cylinder  is  still  present.  The  place  of  the  degenerated 
nerve  elements  has  been  taken  by  proliferated  neuroglia. 
Ganglion  cells  persist  for  long  in  diseased  patches.  In  the 
earlier  stages  and  at  the  margin  of  older  areas  numerous 
granular  cells  containing  fat  globules  are  found.  The  vessels  in 
relation  to  the  patches  often  show  alteration,  such  as  peri-  and 
endarteritis. 

Locomotor  Ataxia  (Tabes  Dorsalis). — This  disease  has 
a  very  definite  relationship  to  syphilis.  It  is  characterised 


DISEASES  OF  THE  SPINAL  CORD  251 

clinically  by  a  peculiar  stamping  gait,  absence  of  knee-jerks, 
loss  of  sense  of  position,  Argyll -Robertson  pupil,  optic 
atrophy,  various  paralyses,  etc. 

The  changes  found  in  fatal  cases  of  the  disease  are  most 
marked  in  the  spinal  cord,  which  shows  a  sclerosis  of  the 
posterior  columns.  To  the  naked  eye  these  columns  are 
translucent  and  shrunken.  There  is  often  thickening  of  the 
membranes  over  the  posterior  portion  of  the  cord.  On  more 
careful  examination  the  distribution  of  the  sclerosis  is  found 
to  vary  according  to  the  level  examined.  In  the  common 
variety,  where  the  change  commences  in  the  lumbar  region, 
examination  of  the  cord  at  that  level  shows  degeneration 
in  the  postero-  external  column.  Sometimes,  in  the  more 
advanced  cases,  both  postero-external  and  postero-internal 
are  sclerosed.  In  such  cases  the  upper  dorsal  and  the  cervical 
segments  show  the  degeneration  mainly  in  the  postero- 
internal  tract.  This  is  due  to  the  fact  that  the  sensory  fibres 
which  run  in  the  posterior  columns  do  so  first  in  the  postero- 
external  tract  and  then  gradually  pass  into  the  postero- 
internal  on  their  way  to  the  ganglia  in  the  medulla.  In 
cases  of  cervical  tabes,  on  the  other  hand,  the  change  is  found 
in  the  postero-external  tract  in  the  cervical  region.  In 
combined  cervical  and  lumbar  cases,  the  whole  of  the  posterior 
columns  is  affected.  Occasionally  other  ascending  tracts, 
such  as  the  direct  cerebellar  and  antero-lateral-ascending,  are 
implicated. 

Microscopically ',  in  the  sclerosed  areas  there  is  found  a 
disappearance  more  or  less  complete  of  the  axis  cylinders  and 
medullary  sheaths,  and  a  replacement  of  these  by  neuroglia. 

In  addition,  degenerative  changes  are  found  in  the  cells 
of  the  spinal  ganglia  in  some  cases  (see  changes  in  nerve  cells, 
p.  247),  also  in  the  peripheral  portions  of  the  sensory  nerves. 

Thus  there  is  in  tabes  a  progressive  degenerative  change 
in  the  sensory  neurons  of  the  cord,  most  marked  in  the  intra- 
medullary  fibres  of  the  posterior  sensory  neuron,  followed  by 


252  DISEASES  OF  THE  NERVES 

a  proliferation  of  the  neuroglia.  As  regards  the  primary 
change  there  is  great  uncertainty  and  considerable  difference 
of  opinion.  Some  regard  it  as  being  the  sclerosis  of  the 
posterior  columns,  others  a  local  meningitis  implicating  the 
posterior  roots  as  they  pass  through  the  meninges  and  so 
cutting  them  off  from  their  trophic  centres.  Others  again 
say  that  the  degeneration  of  the  cells  in  the  posterior  root 
ganglion  is  the  first  lesion. 

Hereditary  Spinal  Ataxia  (Friedreich's  Ataxia). — This 
is  a  disease  which  usually  affects  several  members  of  the 
same  family.  The  lesion  in  the  spinal  cord  is  similar  to 
that  found  in  locomotor  ataxia,  but  in  addition  to  the 
sclerosis  of  the  posterior  columns  there  is  a  similar  change 
in  the  lateral  parts  of  the  cord  affecting  the  crossed  pyramidal 
tracts,  sometimes  also  the  direct  cerebellar  and  antero- 
lateral-ascending  tracts. 

Tumours 

Tumours  of  the  cord  or  its  membranes  are  rare.  Apart 
from  tubercle  nodules  and  gummata,  the  commonest  growth 
is  the  glioma ;  next  comes  the  sarcoma.  Secondary  growths, 
both  sarcomata  and  carcinomata,  are  occasionally  met  with. 

More  common  are  tumours  in  the  vertebrae — sarcomata 
and  carcinomata — pressing  upon  the  cord  and  leading  to 
myelitis. 


DISEASES  OF  THE  PERIPHERAL  NERVES 

Neuritis^  or  inflammation  of  the  nerves,  may  be  due  to  ( i ) 
bacterial  poisons  such  as  in  diphtheria,  (2)  chemical  poisons 
such  as  alcohol,  arsenic,  lead  and  gout,  (3)  trauma,  (4)  extension 
of  inflammation  from  adjacent  parts. 

It  is  customary  to  distinguish  two  types  :  (a)  parenchymatous 
neuritis,  in  which  the  degenerative  change  in  the  axis  cylinders 
and  medullary  sheath  is  the  main  thing.  (b)  Interstitial 


DISEASES  OF  THE  NERVES  253 

neuritis,  in  which  the  overgrowth  of  the  fibrous  tissue  elements 
of  the  nerve  is  the  chief  process.  There  is  in  reality  no  hard 
and  fast  line  between  the  two  types.  When  the  poison  is, 
as  in  diphtheria,  rapid  in  its  action,  the  degenerative  change 
predominates  ;  when  the  poison  is,  like  tuberculosis  or  leprosy, 
slow  in  its  effect,  the  interstitial  process  is  in  the  ascendant. 

In  the  more  acute  cases,  beyond  some  swelling  and 
increased  vascularity  of  the  nerve,  there  is  little  to  be  seen 
with  the  naked  eye.  In  the  more  chronic  types,  nodules  of 
granulation  tissue  and  fibrous  thickening  are  met  with. 

Microscopically ',  specimens  treated  with  osmic-acid  will 
show  black  colouration  of  the  myelin  sheath.  There  is 
infiltration  of  the  connective  tissue  with  inflammatory  cells, 
more  marked  in  the  chronic  cases. 

Tumours. — The  commonest  growth  is  the  fibroma  (so-called 
neuro-fibroma).  Such  tumours  are  often  multiple.  Occasionally 
they  undergo  a  sarcomatous  change. 

Microscopically,  the  swellings  are  found  to  consist  entirely 
of  fibrous  tissue,  the  nerve  fibres  running  through  them. 


CHAPTER  XII 

DISEASES   OF  BONES   AND  JOINTS 

DISEASES  OF  BONES 

RICKETS 

THIS  is  essentially  a  disease  of  infancy,  although  the  results 
of  it  tend  to  persist  throughout  life.  The  underlying  factor 
in  its  production  is  a  deficiency  of  calcareous  material  in 
the  newly-formed  bone. 

The  causation  of  the  disease  is  still  obscure,,  but  deficient 
amount  of  lime  salts  in  the  food  or  failure  to  make  use  of  the 
lime  salts  already  present  is,  in  all  probability,  the  explanation 
of  the  relative  absence  of  these  salts  in  the  bones.  Some 
ascribe  the  condition  to  defective  action  of  ductless  glands, 
which  produce  an  internal  secretion,  such  as  the  pituitary 
and  suprarenal. 

The  changes  found  in  the  body  in  cases  of  rickets  are  as 
follows  : — 

1.  Enlargement  of  the  head  with  prominence  of  the  pro- 
tuberances  of  the  skull  and  thinning  of  the  remainder  of 
the  bony  walls  (cranio tabes).    The  fontanelles  remain  open 
for  an  unusually  long  period. 

2.  Enlargement  of  the  epiphyses  of  the  long  bones  and  of 
the  co sto-chondral  junctions.     The   latter  condition  results 
in  the  formation  of  a  double  row  of  nodules,  the  so-called 

254 


DISEASES  OF  BONES  255 

"rickety-rosary"  (Fig.  105).  On  section  of  one  of  these 
nodules  the  line  of  junction  between  bone  and  cartilage,  which 
should  be  more  or  less  straight,  is  very  irregular  and  vascular. 
3.  Deformation  of  the  bony  skeleton  as  a  result  of  the 
softening  associated  with  the  absence  of  lime  salts. 

(a)  Prominence  of  the  sternum. 

(b)  Curvature  of  the  spine  (kyphosis  and  scoliosis). 

(c)  Curvature  (occasionally  fracture)  of  the  long  bones 
such  as  the  femur.     Sometimes,  consequent  on  the  bending, 
a  new  formation  of  bone  takes  place  along  the  concavity  of 
the  tibia  or  femur  (buttressing). 

(d)  Narrowing  of  the  pelvis  antero-posteriorly,  resulting 
in  difficulty  during  parturition.    Also  throwing  out  of  the 
iliac  bones. 

In  addition,  there  is  often  abnormal  prominence  of  the 
abdomen,  and  dentition  is  usually  delayed. 

Microscopically \  there  is  found  at  the  epiphyses  of  the  bones 
and  at  the  costo-chondral  junctions  (a)  a  broadening  of  the 
zone  where  the  cartilage  cells  are  undergoing  multiplication  ;  at 
the  same  time  there  is  irregularity  in  the  arrangement  of  the 
cartilage  cells. 

(b}  Irregular  calcification  of  the  cartilage. 

(c)  Penetration  of  blood-vessels  into  the  cartilage. 

(tf)  Formation  of  a  spongy  osteoid  tissue  with  deposition  of 
lime  salts  which  can  be  demonstrated  as  granular  material, 
rather  than  a  combination  of  the  lime  salts  with  connective 
tissue  to  form  true  bone. 

At  the  same  time  there  is  a  laying  down  of  a  layer  of 
vascular  tissue  under  the  periosteum,  which  later  undergoes 
ossification. 

OSTEOMALACIA 

This  is  a  rare  disease,  found  especially  in  certain  localities, 
e.g.  the  Rhine  Valley  and  Flanders.  It  is  more  frequent  in 
females  and  has  a  definite  relationship  to  pregnancy. 

It  is  stated  to  have  been  cured  by  the  removal  of  the 
ovaries. 


256          DISEASES  OF  BONES  AND  JOINTS 

The  condition  is  essentially  a  decalcification  of  the  bony 
trabeculse,  beginning  at  the  surface  of  the  bones,  with,  at 
the  same  time,  a  tendency  to  the  formation  of  new  bone 
which  remains  imperfectly  calcified.  As  the  result  of  the 
process  of  softening  and  under  the  influence  of  pressure,  the 
bones  become  deformed  and  sometimes  fractured. 

The  pelvic  bones,  owing  to  the  great  pressure  to  which 
they  are  subjected,  are  usually  the  most  deformed,  with  the 
result  that  there  is  a  crumpling  of  the  bony  wall  of  the  pelvis, 
so  that  the  cavity  is  greatly  narrowed.  Other  bones,  such  as 
the  vertebrae,  clavicles,  and  femur,  undergo  a  similar  process 
of  bending. 

INFLAMMATION  OF  BONE 

The  inflammatory  process  as  it  occurs  in  relation  to 
bone  shows  certain  peculiarities  due  in  great  measure  to 
the  physical  characters  of  the  tissue  and  to  the  anatomical 
arrangement  of  its  constituents. 

From  the  point  of  view  of  inflammation,  three  different 
parts  of  a  bone  may  be  distinguished — (i)  the  periosteum,  a 
vascular  connective  tissue  structure  which  covers  the  exterior 
of  the  bone  and  from  which  the  nourishing  vessels  enter  the 
bone.  When  the  periosteum  is  stripped  from  the  underlying 
bone,  as  it  may  be  artificially  or  by  the  accumulation  of 
exudate,  the  more  superficial  parts  of  that  bone  tend  to 
undergo  necrosis.  Further,  the  periosteum  has  the  capacity 
of  forming  new  bone,  and  under  the  influence  of  chronically 
acting  poisons  this  function  is  stimulated.  (2)  The  bone 
itself  is  a  rigid  non-expansible  tissue,  dependent  for  its  nourish- 
ment upon  the  vessels  which  pass  into  it  from  periosteum 
and  medulla.  When  it  is  the  seat  of  the  more  acute  types  of 
inflammation,  the  exudate  from  the  vessels,  unable  to  infil- 
trate the  rigid  tissue  around,  accumulates  and  presses  upon 
the  vessels,  thus  leading  to  necrosis  of  the  bone.  In  the  less 
acute  types  of  inflammation,  probably  in  order  that  there 


DISEASES  OF  BONES  257 

may  be  space  for  the  inflammatory  reaction,  the  hard  re- 
sisting bone  is  excavated  by  means  of  large  cells  (osteo- 
clasts).  This  rarefaction  of  the  bone  is  known  variously  as 
osteo-porosis  or  caries.  (3)  The  medulla  or  bone  marrow,  also 
a  vascular  tissue,  having  as  its  function  the  nourishment  of 
the  bone  and  also  the  formation  and  destruction  of  blood. 

When  inflammation  attacks  bones  the  process  usually 
commences  in  one  or  other  of  the  vascular  structures — 
periosteum  or  medulla ;  by  far  most  commonly  in  the  latter. 
As  the  process  extends,  it  tends  to  involve  the  other  structures, 
so  that  periostitis  usually  accompanies  osteomyelitis  and 
vice  versa. 

The  causation  of  the  inflammatory  process  may  be  (i) 
injury ;  (2)  organisms  such  as  the  pyogenic  cocci,  B.  typhosus, 
B.  tuberculosis,  the  organism  of  syphilis,  etc. 

Three  processes  are  found  going  on,  often  side  by  side,  in 
inflammation  of  bone :  (i)  Necrosis  or  death  of  bone ;  (2) 
New  formation  of  bone  which  is  often  hard  (sclerosis)  but  may 
be  porous ;  (3)  Rarefaction  of  the  pre-existing  or  newly-formed 
bone  (osteo-porosis  or  caries).  In  the  case  of  the  more  acutely 
acting  irritants  the  necrotic  process  tends  to  predominate, 
owing  to  the  tendency  for  exudate  to  accumulate  and  to 
obliterate  vessels  and  separate  periosteum.  In  the  case  of  the 
more  chronically  acting  poisons — prolonged  coccal  infection, 
tuberculosis  and  syphilis — the  rarefying  process  is  met  with 
along  with  new  formation  of  bone.  This  laying  down  of  new 
bone  is  merely  a  modification  of  fibrosis  or  interstitial  inflam- 
mation due  to  the  fact  that  the  new  connective  tissue  contains 
bone-forming  elements. 

Acute  Osteomyelitis. — This  condition  sometimes  occurs 
during  the  course  of  specific  fevers,  but  often  occurs  spontane- 
ously. Young  children  are  particularly  susceptible.  Some- 
times there  is  a  history  of  an  injury  to  the  bone,  at  other 
times  the  disease  arises  without  any  such  predisposing  cause. 

17 


258          DISEASES  OF  BONES  AND  JOINTS 

The  condition  is  an  organismal  one,  staphylococcus  pyogenes 
aureus  being  very  commonly  present,  but  other  staphylococci, 
streptococci  and  B.  typhosus  are  occasionally  found.  The 
organism  reaches  the  bone  marrow  by  way  of  the  blood- 
stream, having  been  absorbed  from  the  throat  or  intestinal 
tract  or  other  focus  of  infection.  The  area  of  marrow  in- 
volved shows  congestion  of  its  vessels,  purulent  infiltration 
and  haemorrhages.  Sometimes  localised  areas  of  suppuration 
(abscesses)  develop  in  the  bone.  The  periosteum  is  very 
commonly  involved  and  pus  may  accumulate  under  that 
membrane.  In  this  way  necrosis,  more  or  less  extensive, 
may  occur  in  the  shaft  of  the  bone  with  formation  of 
sequestra.  Sometimes  the  epiphyses  and  joints  are  involved. 

Owing  to  the  occurrence  of  thrombosis  in  the  veins  in  the 
neighbourhood  and  subsequent  infective  softening  of  the 
thrombi,  metastatic  abscesses  and  septic  infarcts  may  form 
in  other  parts  and  organs,  especially  in  the  lungs.  Peri- 
carditis is  not  an  uncommon  accompaniment  of  acute  osteo- 
myelitis, the  infection  being  carried  by  the  blood. 

The  bones  which  are  most  frequently  affected  are  the 
femur  and  tibia,  although  other  bones  may  be  the  seat  of  the 
change  by  extension  of  inflammation  from  neighbouring  parts, 
e.g.  the  bones  of  the  skull  or  finger  in  cases  of  septic  wounds. 
Rarely  the  vertebrae  may  be  affected. 

Chronic  Osteomyelitis. — Healing  of  the  inflamed  focus 
may  occur  spontaneously,  or,  as  is  most  usually  the  case,  the 
diseased  area  may  be  removed  by  the  surgeon,  and  healing 
result.  At  other  times  the  inflammatory  change  persists. 
Organisms  remain  in  portions  of  dead  bone  (sequestra),  and 
the  irritation  is  kept  up.  From  such  foci  a  purulent  dis- 
charge is  constantly  flowing,  which  finds  its  way  to  the  surface 
by  openings  in  the  bone  (cloacae)  and  sinuses  in  the  soft  parts. 
At  the  same  time  the  periosteum,  kept  in  a  constant  state 
of  proliferation,  forms  new  bone  which  may  enclose  the 


DISEASES  OF  BONES  259 

sequestra  or  dead  areas,  forming  what  is  called  a  "  new  case." 
This  new  bone  usually  has  a  spongy  character  but  may  be 
dense  (Fig.  106). 

Waxy  disease  is  not  infrequently  found  in  relation  to 
chronic  suppurative  conditions  of  bone. 

Tuberculosis  of  Bone.— Tuberculous  disease  of  bones  is 
met  with  more  especially  in  young  children,  i.e.  in  growing 
bones,  although  the  results  of  such  disease  are  often  seen  in 
the  adult.  A  large  percentage  of  cases  are  due  to  infection 
with  the  bovine  type  of  the  tubercle  bacillus.  The  organism 
may  reach  the  bone  by  the  blood-stream  or  by  the  lymphatics. 
In  the  latter  instance  the  primary  focus  is  usually  the  synovial 
membrane  of  a  neighbouring  joint.  The  bones  most  frequently 
involved  are  the  vertebrae  (Fig.  107),  femora,  the  tarsal  and 
carpal  bones,  and  the  ribs. 

The  condition  may  begin  in  the  interior  of  the  bone, 
usually  in  the  cancellous  tissue  at  the  ends  (in  the  case  of  the 
long  bones)  or,  much  less  frequently,  in  the  periosteum. 
It  appears  first  as  a  grey  translucent  area  surrounded  by  a 
vascular  zone.  This  area  spreads,  gradually  absorbing  the 
bone,  and  so  producing  rarefaction  or  caries.  At  the  same 
time,  owing  to  the  irritation  of  the  focus,  new  bone  may  be 
laid  down  in  the  neighbourhood,  particularly  under  the 
periosteum.  In  rapidly  progressive  cases,  largely  owing  to 
obliterative  changes  in  the  vessels,  but  also  due  to  the  action 
of  the  tubercle  poison,  necrosis  of  larger  or  smaller  areas  of 
bone  occurs,  with  formation  of  sequestra. 

The  change  may  spread  to  the  surrounding  parts  and  a 
tuberculous  (so-called  "  cold  ")  abscess  develop  in  the  tissues. 
This  is  particularly  the  case  in  tuberculosis  of  the  vertebrae ; 
retropharyngeal  abscess  occurring  in  connection  with  cervical 
disease,  psoas  abscess  in  relation  to  lumbar  disease  (Fig.  107). 
Sometimes  the  focus  infects  the  spinal  cord,  setting  up  a 
meningitis. 


260          DISEASES  OF  BONES  AND  JOINTS 

Deformity  of  bone  frequently  follows  tuberculous  disease. 
This  is  more  especially  seen  in  tuberculosis  of  the  spine. 

Syphilis  of  Bone. — Bone  may  be  the  seat  of  disease  both 
in  congenital  and  acquired  syphilis. 

In  congenital  syphilis  the  disease  shows  itself  chiefly  at  the 
ends  of  the  long  bones  in  the  part  where  ossification  is  taking 
place  (syphilitic  epiphysitis).  The  line  of  calcification  is 
broader  and  more  irregular  than  normal.  The  result  of  this 
is  an  interference  with  growth  leading  to  a  form  of  dwarfing. 

In  the  acquired  form  of  the  disease  the  lesion  is  essentially 
gummatous.  Such  gummata  may  occur  in  the  periosteum 
or  in  the  medulla  of  the  bone.  The  process  may  be  found  in 
any  part  of  the  skeleton,  but  it  is  commonest  in  the  tibia, 
ulna,  sternum  and  calvarium.  Underneath  the  gumma  there 
is  erosion  of  the  bone  which  has,  in  the  case  of  the  calvarium, 
a  characteristic  circular  appearance  (corona  veneris). 

Sometimes  thickenings  occur  in  the  bones  (long  and  flat) 
leading  to  the  formation  of  raised  areas  (syphilitic  nodes). 
The  newly-formed  bone  is  in  these  cases  very  dense. 

Osteitis  Deformans  (Paget's  disease  of  bone). — This  is  a 
rare  disease  of  advanced  life. 

There  is  a  general  thickening  of  such  bones  as  the  tibiae 
clavicles,  skull,  and  vertebrae.  The  bones  are  at  the  same 
time  spongy  and  relatively  light,  although  the  medullary 
cavity  is  narrowed  from  the  formation  of  new  bone.  Owing 
to  the  softness  of  the  bones  deformity  occurs,  particularly 
in  bones,  such  as  the  lower  extremities,  spine  and  clavicles, 
which  are  subjected  to  pressure. 

Acromegaly,  a  condition  caused  by  disease  of  the  pituitary 
gland,  is  associated  with  an  enlargement  of  certain  bones, 
e.g.  the  lower  jaw,  bones  of  the  face,  hands  and  feet.  The 
enlargement  is  due  to  a  laying  down  of  new  bone  as  well  as 
to  a  thickening  of  the  periosteum. 


DISEASES  OF  JOINTS  261 

Tumours  of  Bone. — Of  simple  tumours,  osteomata, 
chondromata  and  fibromata  are  met  with. 

Of  malignant  growths,  sarcomata  of  various  kinds 
occur  primarily — Osteo-sarcomata  (Fig.  108),  chrondro  sar- 
comata, myeloid  sarcomata  (Fig.  109),  and  myelomata. 

Secondary  deposits  of  carcinoma  are  occasionally  met, 
particularly  in  carcinoma  of  the  breast  and  prostate. 

DISEASES  OF  JOINTS 

INFLAMMATION  (ARTHRITIS) 

Acute  Arthritis. 

1.  Non-suppurative. — This  is  found  following  injury  and 
in  connection  with  acute  rheumatism.    In  the  latter  instance, 
the  synovial  membrane  is  swollen  and  shows  irregularly 
scattered  areas  of  congestion.    There  is  excess  of  a  thin 
yellowish  fluid  in  the  joint.    From  the  inflamed  synovial 
membrane  (not  from  the  fluid  as  a  rule)  micrococcus  rheumaticus 
can  in  some  cases  be  cultivated. 

2.  Suppurative  Arthritis. — This  may  occur  in  the  course 
of  a  pyaemia,  the  organisms  being  conveyed  by  the  blood, 
or  infection  may  take  place  directly,  due  to  a  penetrating 
wound  or  inflammation  in  bone  or  neighbouring  tissues. 
The  germs  found  are  the  pyogenic  cocci,  more  especially 
streptococci  and  gonococci. 

The  synovial  membrane  is  swollen  and  its  vessels  injected. 
The  joint  contains  more  or  less  purulent  fluid,  often  mixed 
with  blood.  In  the  more  severe  forms,  particularly  the 
gonococcal,  there  is  destruction  of  the  cartilages  of  the  bones. 

Tuberculous  Disease. — Tuberculosis  may  commence  in 
the  synovial  membrane  of  the  joint  or  it  may  spread  from  the 
adjacent  bone. 

In  a  well-marked  case  of  joint  disease  there  is  a  general 
pallor  of  the  tissues  in  the  neighbourhood.  There  is  some 


262  DISEASES  OF  BONES  AND  JOINTS 

increase  of  synovial  fluid  which  is  serofibrinous  and  occasion- 
ally purulent.  The  synovial  membrane  is  thickened,  some- 
times with  the  formation  of  fringes.  The  cartilage  is  eroded 
through  the  invasion  of  granulation  tissue  from  the  margins 
of  the  bones.  There  may  be  caries  or  sequestrum  formation 
in  the  exposed  bone.  In  advanced  cases  the  tendons  and 
ligaments  in  connection  with  the  joint  are  infiltrated  with 
tubercle.  The  joints  most  commonly  affected  are  hip,  knee, 
elbow  and  ankle.  The  condition  may  heal,  with  the  result 
that  ankylosis  frequently  occurs. 

Rheumatoid  Arthritis. — This  is  a  disease  which  is 
found  most  frequently  in  females.  The  small  joints  of  the 
hands  and  feet  are  usually  first  affected.  Later  on  those  of 
the  elbow  and  knee  are  involved.  The  joints  show  a  fusiform 
swelling  and  contain  excess  of  clear  synovial  fluid.  The 
synovial  membrane  is  swollen  and  congested,  and,  even  in 
the  early  stage,  there  may  be  some  fibrillation  and  destruc- 
tion of  cartilage.  The  condition  is  not  often  found  in  the 
post-mortem  room  in  the  early  stage. 

In  the  later  stages  of  the  disease,  erosion  of  cartilage  with 
eburnation  or  polishing  of  the  bone  laid  bare,  also  new  forma- 
tion of  bone  at  the  margins  of  the  joint  (lipping),  are  character- 
istically present.  At  the  same  time  there  is  marked  deformity 
as  well  as  restriction  of  movement,  due  both  to  the  lipping 
of  the  bones  and  to  the  formation  of  fibrous  tissue  between 
them. 

Gout. — This  condition  should  be  looked  for  specially  in  the 
metatarsophalangeal  joint  of  the  great  toe.  It  shows  itself 
by  deposits  of  opaque  white  material  (salts  of  uric  acid) 
in  the  cartilage  and  in  advanced  cases  in  ligaments  and 
soft  tissues.  There  is  chronic  inflammation  in  the  tissues 
around. 

Charcot's  Disease  of  Joints. — This  is  a  rare  condition, 
found  sometimes  in  individuals  suffering  from  locomotor 


,  DISEASES  OF  JOINTS  263 

ataxia  and  syringomyelia.  There  is  a  great  enlargement  of 
the  joint  due  to  the  accumulation  of  fluid  in  it,  also  increased 
mobility.  There  is  later  destruction  of  the  cartilage,  bones 
and  ligaments,  the  condition  being,  however,  painless.  The 
synovial  membrane  is  thickened,  and  may  show  villous 
outgrowths. 


CHAPTER   XIII 

DISEASES   OF  THE  REPRODUCTIVE   ORGANS   AND    MAMMARY 
GLAND — DISEASES   OF  PREGNANCY 

DISEASES   OF   THE  OVARIES 

THE  appearances  of  the  ovary  in  menstruating  women  should 
be  carefully  differentiated  from  those  seen  in  disease. 

The  organ  is  swollen  and  vascular,  and  haemorrhagic  areas 
occur  in  it.  Occasionally  severe  haemorrhage  may  occur 
into  the  peritoneal  cavity.  Similarly  corpora  lutea,  with  their 
yellow  colour  and  characteristic  wavy  outline,  should  be 
distinguished  from  tumours. 

In  acute  inflammations  of  the  peritoneum  the  ovaries  and 
tubes  participate  in  the  inflammatory  condition,  and  often 
show  marked  vascularity.  This  should  not  be  mistaken  for 
evidence  of  primary  inflammation  in  these  organs.  In  old  age 
the  organs  undergo  atrophy.  The  capsule  becomes  thickened 
and  shrivelled. 

Tumours. — The  ovary  is  one  of  the  organs  in  which 
tumours  are  exceedingly  common.  As  a  rule  such  tumours 
are  cystic. 

Single  cysts  occasionally  occur  from  dilatation  of  a  Graafian 
follicle.  Solitary  cysts  also  develop  sometimes  from  the 
parovarium. 

Compound  Cystic  Adenoma. — This  is  a  common  tumour 
which  may  attain  an  enormous  size.  It  consists  of  a  number 

264 


DISEASES  OF  THE  FALLOPIAN  TUBES      265 

of  rounded  or  irregularly  shaped  spaces  enclosing  a  translucent 
or  transparent  gelatinous  or  semi-solid  material  containing 
various  mucinous  constituents.  Not  infrequently  small 
papillomatous  ingrowths  are  found  within  the  cysts  which 
divide  and  subdivide.  When  such  are  present  the  term 
papilliferous  cystadenoma  is  applied.  Such  a  tumour,  like  the 
similar  one  found  in  the  breast,  may  undergo  a  malignant 
transformation.  When  these  cystic  tumours  of  the  ovary 
rupture  they  sometimes  give  rise  to  the  formation  of  immense 
numbers  of  secondary  growths  scattered  through  the  peri- 
toneum. 

For  microscopic  appearances  see  pp.  285,  286. 

Dermoid  Cysts  (Teratomatd). — The  ovary  is  the  commonest 
site  for  this  type  of  tumour.  They  vary  much  in  size. 
They  are  recognised  by  the  soapy-looking  contents  mixed 
with  hair  and  containing  often  teeth,  cartilage,  bone,  etc. 
(Fig.  102). 

Fibromata  occasionally  occur  in  the  ovary,  also  fibro- 
sarcomata  which  may  attain  a  large  size. 

DISEASES  OF  THE  FALLOPIAN  TUBES 

Salpingitis. — Two  types  of  this  condition  are  met  with, 
viz.  gonococcal  and  tuberculous.  In  the  former  the  tubes 
are  thickened  and  dilated,  and  contain  creamy  or  cheesy- 
looking  pus,  which  in  many  cases  is  found  to  be  sterile. 

In  the  tuberculous  type  there  is  a  similar  dilatation,  thicken- 
ing and  tortuosity.  Minute  grey  tubercles  may  be  visible 
in  the  walls ;  the  contents  are  often  caseous.  These  two 
conditions  are  sometimes  to  be  differentiated  only  on  micro- 
scopic examination. 

Both  give  rise  to  localised  peritonitis  with  adhesions,  and 
both  may  be  the  starting-point  of  a  generalised  inflammation 
of  the  peritoneum. 

The  Fallopian  tube  is  the  commonest  site  for  the  occur- 


266  DISEASES  OF  THE  REPRODUCTIVE  ORGANS 

rence  of  ectopic  gestation.    Death  occurs  from  rupture  and 
haemorrhage  into  the  peritoneal  cavity. 


DISEASES   OF   THE  UTEEUS 

The  size  of  the  uterus  should  in  all  cases  be  measured  and 
its  cavity  investigated  for  developing  ovum  or  foetus. 

Thrombosis  in  the  uterine  veins  is  a  constant  occurrence 
after  parturition.  Occasionally  portions  of  such  thrombi  are 
carried  away,  and  produce  fatal  pulmonary  embolism. 

Sometimes,  after  operations  on  the  uterus  or  ovaries,  a 
similar  accident  may  occur.  In  such  cases  the  emboli  may 
originate  from  vessels  in  the  neighbourhood  of  the  removed 
growth  or  organ  or  from  the  abdominal  wound. 

Acute  Endometritis. — This  condition  is  a  not  uncommon 
cause  of  death  in  puerperal  cases.  The  disease  is  an  infective 
one,  due  as  a  rule  to  a  streptococcus.  A  gram-negative  coccus 
not  unlike  the  gonococcus  has  been  recently  described  as 
occurring  in  the  uterus  in  such  cases. 

The  organ  is  of  course  enlarged.  The  interior  has  a  grey 
appearance,  owing  to  the  presence  of  septic  sloughs  in  the  wall. 
There  is  usually  a  foul  odour.  Films  from  the  soft  necrotic 
interior  show  immense  numbers  of  organisms,  among  them 
streptococci.  The  uterine  veins  are  filled  with  thrombi,  which 
may  be  undergoing  septic  softening.  Septic  infarcts  are  not 
uncommonly  present  in  the  lungs. 

Organs  such  as  liver,  kidneys,  and  heart  show  extreme 
cloudy  swelling.  Acute  peritonitis  localised  to  the  neighbour- 
hood of  the  uterus  or  generalised  throughout  the  peritoneum 
may  be  present. 

Microscopically,  the  innermost  portion  of  the  uterine  wall 
shows  necrosis.  Numerous  germs  of  various  kinds  are  present. 
Further  from  the  lumen  the  uterine  muscle  is  infiltrated  with 
inflammatory  cells,  and  thrombi  are  found  in  the  vessels  ;  in 


DISEASES  OF  THE  UTERUS  267 

this    position    in   suitably   stained   specimens  streptococci  are 
usually  the  only  organisms  seen. 

Chronic  Endometritis. — Two  types  of  this  condition 
are  commonly  distinguished :  (i)  glandular  endometritis,  (2) 
interstitial  endometritis. 

1.  Glandular  endometritis  is  also  called  glandular  hyper- 
plasia.     It  is  questionable  whether  this  condition  is  in  reality 
an  inflammatory  one.     There   is  little  or  no  evidence   of 
inflammation   from   the  microscopic  point  of  view.      The 
main  change  is  a  hyperplasia  of  the  gland  elements  of  the 
endometrium.    Many  regard  it  as  neoplastic  in  nature,  i.e. 
an  adenoma. 

The  uterus  is  enlarged  and  its  mucous  membrane  thick- 
ened, vascular  and  spongy.  Polypoid  outgrowths  may  be 
associated. 

Microscopic  Appearances. — Sections  of  the  uterine  wall  show 
gland  acini  more  or  less  regularly  arranged,  but  often  tortuous 
and  sometimes  dilated,  between  which  is  a  delicate  stroma  of 
connective  tissue.  The  gland  acini  may  often  be  seen  pene- 
trating the  muscular  wall  for  some  distance,  so  that  the  con- 
dition may  be  confused  with  an  adeno-carcinoma  of  the  uterine 
wall.  The  gland  cells  are,  however,  only  a  single  layer  in 
thickness,  and  are  arranged  regularly  upon  a  basement  mem- 
brane, although  there  is  sometimes  shedding  of  the  cells. 

Sections  of  curettings  from  a  case  of  this  kind  present  a 
similar  appearance. 

2.  Interstitial  endometritis  is  often  combined  with  chronic 
metritis.    It  has  been  called  fibrosis  uteri.    The  uterus  is 
larger,  firmer,  and  heavier  than  normal. 

Microscopically ',  curettings  show  a  dense  fibrous  stroma, 
in  which  the  vessels  are  thickened.  The  gland  acini  are 
usually  few  in  number  and  widely  separated  from  one  another. 

Tuberculosis  of  the  uterus  is  a  rare  condition.  It  may 
occur  as  an  endometritis  with  the  development  of  ragged 


268  DISEASES  OF  THE  REPRODUCTIVE  ORGANS 

caseous  walls,  or  fibro-caseous  nodules  may  occur  in  the  wall 
of  the  uterus  which  is  usually  considerably  thickened. 

Tumours.  —  Of  simple  growths  the  fibro-myoma  (leio- 
myoma),  or  tumour  composed  of  non-striped  muscle  and 
fibrous  tissue,  is  the  commonest  (Fig.  104).  A  full  description 
is  found  under  Tumours,  p.  280. 

Of  malignant  growths  the  carcinoma  is  very  common. 
Two  main  types  are  found  : — 

1.  Squamous  epithelioma  occurring  in  the  cervix. 

2.  Columnar  cell  carcinoma  occurring  in  the  body  or  cervix. 

DISEASES  OF   THE  PLACENTA 

Infarcts,  i.e.  areas  of  necrosis  in  the  placenta,  are  not 
uncommon.  They  are  best  developed  in  cases  of  eclampsia. 
They  appear  as  opaque  white  or  pale  yellow  areas, 
more  or  less  wedge  shaped,  and  towards  the  maternal  surface. 
They  are  caused  by  thrombosis  in  the  intervillous  blood 
spaces. 

Fibrosis. — Under  the  influence  of  the  syphilitic  virus  the 
placenta  becomes  larger,  firmer,  and  paler,  and  may  present 
a  dull,  greasy  appearance. 

Microscopically,  the  chorionic  villi  are  found  to  be  thicker 
and  show  a  marked  decrease  in  the  number  of  vessels.  In  the 
thickened  stroma  are  numerous  round  and  spindle-shaped  cells. 

Tumours. — Hydatid  mole  or  myxoma  of  the  chorion  is  a 
condition  in  which  chorionic  villi  become  greatly  enlarged  and 
cedematous.  The  tumour  shows  immense  numbers  of 
translucent  globular  masses  like  white  currants,  varying  much 
in  size,  strung  upon  thin  filaments.  The  condition  occurs 
after  an  abortion.  It  may  become  malignant,  passing  into 
the  condition  known  as  chorion-epithelioma  (p.  304). 

Microscopically,  the  globular  masses  show  the  structure  of 
myxomatous  tissue,  hence  the  term  myxoma  of  the  chorion. 


DISEASES  OF  PREGNANCY  269 

There  is  at  the  same  time  proliferation  of  the  covering  epithelial 
layers — syncytium  and  Langhan's  layer. 

Chorion  epiihelioma  or  Deciduoma  malignum  is  a  tumour 
formation  which,  like  the  preceding,  has  a  distinct  relation- 
ship to  pregnancy  and  abortion.  Its  appearance  and  nature 
are  discussed  under  Tumours  (p.  304).  It  is  associated  with  the 
development  of  secondary  growths,  particularly  in  the  lung. 


DISEASES  OF  PREGNANCY  AND  THE  PUEBPERIUM 
WHICH  MAY  BE  FATAL 

It  is  convenient  to  discuss  here  some  of  the  diseases  of 
pregnancy  and  the  puerperium  which  may  be  seen  in  the  post- 
mortem room.  Pregnant  and  puerperal  women  may,  of  course, 
die  of  intercurrent  diseases  of  various  kinds.  Thus,  heart 
disease  and  kidney  disease  are  not  uncommonly  a  cause  of 
death  under  such  circumstances.  There  are,  however,  certain 
conditions  more  directly  associated  with  the  pregnant  state 
which  may  prove  fatal. 

In  the  first  place  there  is  ectopic  gestation.  When  an 
ovum  develops  in  a  situation  other  than  the  uterus,  such 
as  the  Fallopian  tubes  or  ovary,  death  not  infrequently 
occurs  from  haemorrhage  into  the  peritoneal  cavity. 

Rupture  of  the  uterus  may  occur  during  pregnancy  or 
during  labour,  with  resulting  fatal  haemorrhage. 

Pulmonary  embolism  has  already  been  alluded  to  as  a 
cause  of  sudden  death  after  labour. 

Chorea  gravidarum  may  prove  fatal.  In  a  case  which  came 
under  the  author's  notice  recently  there  was  present — what 
is  usually  found  in  any  fatal  case  of  chorea — acute  simple 
endocarditis  of  the  mitral  valve. 

Puerperal  fever,  one  of  the  commonest  causes  of  death 
after  labour,  has  already  been  dealt  with  under  Diseases  of 
the  Uterus  (acute  endometritis)  (p.  266). 


270  DISEASES  OF  THE  REPRODUCTIVE  ORGANS 

Hyperemesis  Gravidarum  or  Pernicious  Vomiting  of 
Pregnancy. — This  condition  of  severe  and  sometimes  fatal 
vomiting  developing  during  pregnancy  is  believed  by  authori- 
ties to  be  toxsemic  in  origin,  and  probably  allied  to  such 
diseases  as  eclampsia  and  acute  liver  atrophy.  In  many 
cases  lesions  of  the  liver,  similar  to  those  occurring  in  the 
latter  disease,  are  found.  In  some  cases  the  liver  shows  a 
fatty  degeneration  of  an  extreme  degree ;  in  others  there  are 
areas  of  necrosis  similar  to  those  found  in  eclampsia,  but 
instead  of  being  situated  at  the  periphery  of  the  lobule,  as 
in  that  disease,  they  occur  in  the  centre.  Degenerative 
changes  of  a  type  similar  to  those  in  eclampsia  are  found  in 
the  kidney.  The  condition  is  associated  with  a  high  ammonia 
co-efficient  in  the  urine,  and  there  is  a  corresponding  marked 
reduction  in  the  output  of  urea. 

Acute  Liver  Atrophy.  —  As  already  stated,  there  is  a 
distinct  relationship  between  this  condition  and  the  pregnant 
state.  For  a  description  of  the  lesions  found  in  the  liver  see 
p.  183. 

Eclampsia. — This  is  perhaps  the  commonest  cause  of 
death  in  such  cases.  The  disease  may  prove  fatal  either 
during  pregnancy  or  after  the  birth  of  the  child.  It  is 
associated  clinically  with  more  or  less  marked  albuminuria 
(sometimes  also  blood  and  casts)  and  with  the  occurrence 
of  fits. 

The  cause  of  the  condition  is  at  present  uncertain. 

As  regards  the  post-mortem  findings  in  fatal  cases  of  the 
disease,  these  vary  considerably  in  different  cases.  There 
are,  however,  certain  appearances  found  with  considerable 
constancy.  Post-mortem  changes  are  often  specially  well 
marked.  There  is  often  a  general  icteric  tint  of  the  skin. 
(Edema  of  the  subcutaneous  tissues  may  be  present. 
Excess  of  fluid  in  the  peritoneal,  pleural,  and  pericardial  sacs 
is  also  a  fairly  constant  finding.  The  heart  muscle  is  pale 


DISEASES  OF  PREGNANCY,  ETC.  271 

and  soft.    The  organs  which  show  the  most  constant  changes 
are  the  liver  and  kidneys. 

The  appearances  in  the  liver  when  well  marked  are  exceed- 
ingly characteristic.  The  organ  is  usually  somewhat  enlarged. 
The  surface  has  a  dark  red  appearance,  either  in  whole  or  in 
part  from  the  occurrence  of  more  or  less  extensive  subcapsular 
haemorrhage.  In  consistence  it  is  usually  soft.  The  cut 
surface  shows  a  yellow  appearance,  with  haemorrhages 
scattered  through  the  substance,  chiefly  in  the  portal  spaces. 
The  necrotic  areas,  so  characteristically  present  when  sections 
are  examined  under  the  microscope,  are,  as  a  rule,  too  small 
to  be  seen  by  the  naked  eye.  Occasionally  the  liver  may 
show  the  appearances  of  cloudy  swelling  and  early  fatty 
change  without  the  occurrence  of  haemorrhages. 

Microscopically,  there  are  found  (i)  changes  in  the  liver 
cells  characteristic  of  cloudy  swelling  ;  (2)  more  or  less  marked 
fatty  change  intensified  round  the  necrotic  foci ;  (3)  areas  of 
focal  necrosis  somewhat  similar  to  those  found  in  typhoid  fever 
in  which  the  liver  cells  have  undergone  extreme  degenerative 
changes.  They  are  swollen  and  vacuolated,  or  have  broken 
down  and  disappeared.  Fatty  change  is  not  as  a  rule  present 
in  the  cells  within  such  foci.  Endothelial  cells  and  leucocytes 
are  present  along  with  red  blood  corpuscles.  These  necrotic 
foci  are  found  chiefly  at  the  margin  of  the  lobules  ;  (4)  areas 
of  haemorrhage  in  which  the  tissue  is  infiltrated  with  red  blood 
corpuscles. 

Changes  in  the  Kidney. — As  previously  stated,  there  is  in 
the  urine  distinct  evidence  that  the  kidney  is  damaged,  that, 
in  other  words,  a  degree  of  acute  nephritis  is  present.  But 
even  in  cases  where  the  urine  shows  most  indications  of 
disease  comparatively  little  change  may  be  found  in  the 
kidney  itself,  more  especially  microscopically.  The  organ  is 
somewhat  enlarged  and  pale.  On  section,  the  cortex  is 
swollen  and  tends  to  stand  up  above  the  level  of  the  medulla 
(Fig.  83).  The  colour  of  the  cortex  is  a  pale  yellow, 


272  DISEASES  OF  THE  REPRODUCTIVE  ORGANS 

occasionally  with  haemorrhages  scattered  through  it.  In 
consistence  the  organ  is  softer  than  usual.  Unless  the  case 
is  complicated  with  chronic  renal  disease,  the  capsule  strips 
perfectly,  leaving  a  smooth,  pale  surface. 

Microscopically,  as  already  indicated,  the  changes  are  less 
marked  than  one  would  have  expected  from  the  examination 
of  the  urine.  There  is  ( i )  always  more  or  less  evidence  of 
cloudy  swelling  of  the  renal  epithelial  cells,  especially  of  the 
cells  lining  the  convoluted  tubules.  (2)  There  is  more  or 
less  fatty  change  in  these  cells,  but  this  is  never  very  marked. 

(3)  There  is  a  certain  amount  of  shedding  (catarrh)  of  these 
cells  with  a  massing  of  the  shed  cells  in  the  collecting  tubules. 

(4)  There  may  be  escape  of  red  cells  into  the  tubules. 

The  appearances  are,  in  short,  those  of  marked  cloudy 
swelling  or  of  an  acute  catarrhal  nephritis,  and,  as  already 
stated,  between  these  two  conditions  there  is  no  very  hard  and 
fast  line. 

It  should  be  remembered  in  connection  with  the  micro- 
scopic appearances  of  the  kidneys  that  a  degree  of  cloudy 
swelling  (toxic  change)  is  practically  constantly  found  in 
pregnancy. 

As  already  mentioned,  infarcts  in  the  placenta  are  specially 
frequent  in  cases  of  eclampsia. 


DISEASES  OF  THE  MAMMAEY  GLAND 

Little  need  be  said  in  such  a  treatise  about  diseases  of  the 
mammary  gland.  Owing  to  their  being  readily  removable, 
growths  of  the  gland  are  seldom  seen  post  mortem. 

Acute  inflammatory  conditions  (acute  mastitis)  with 
abscess  formation  are  not  uncommon. 

Chronic  inflammation  (chronic  interstitial  mastitis)  is 
difficult  to  distinguish  clinically  and  by  the  naked  eye  from 
carcinoma.  It  occurs  as  a  hard  mass,  ill  defined,  in  the 
substance  of  the  gland.  On  section  it  appears  as  white- 
looking  tissue  radiating  through  the  fatty  tissue  of  the  breast. 


DISEASES  OF  THE  TESTICLE  273 

Microscopically -,  the  condition  is  characterised  by  the  develop- 
ment of  a  large  amount  of  well-formed  fibrous  tissue  with 
isolated  islands  of  gland  tissue  scattered  through  it.  Cysts 
formed  by  dilated  gland  acini  are  often  present. 

Tuberculosis  is  occasionally  met  with  in  the  form  of 
multiple  caseous  foci  surrounded  with  fibrous  tissue  scattered 
through  the  gland  substance. 

Tumours. — The  mammary  gland  is  one  of  the  organs  in 
which  tumour  formation  is  most  common.  No  doubt  this 
is  due  to  the  fact  that  the  breast  is  periodically  undergoing 
hypertrophy  and  involution  and  also  to  the  irritation  to  which 
it  is  subjected  from  trauma  and  acute  inflammatory  processes. 

Simple  tumours,  such  as  adenoma  and  cystic  adenoma, 
are  dealt  with  among  tumours  under  these  headings  (p.  285). 

Carcinomata  are  dealt  with  under  adeno-carcinomata. 

Although  primary  carcinomata  of  the  breast  are  seldom 
met  with  in  the  post-mortem  room,  the  secondary  deposits 
are  frequently  seen.  They  may  occur  in  the  lungs  (Fig. 
55),  or  disseminated  through  the  body,  often  showing  a 
marked  preference  for  bone. 


DISEASES    OF   THE   TESTICLE 

Such  diseases  do  not  often  come  under  the  notice  of  the 
pathologist. 

Tuberculosis  of  the  testicle  is  not  infrequently 
associated  with  generalised  tubercle  and  with  tubercle  of  the 
genito-urinary  tract.  The  condition  tends  to  develop  first 
in  the  epididymis  and  may  remain  localised  there. 

Syphilis. — Two  chief  types  of  syphilis  are  found  in  the 
testicle. 

1.  Gummata. — These  are  firm  white  or  yellow  caseous- 
looking  masses  which  ha  veto  be  distinguished  from  sarcomata. 

2.  Interstitial  Inflammation  or  Fibrosis. — A  slight  degree 

18 


274  DISEASES  OF  THE  REPRODUCTIVE  ORGANS 

of  this  is  not  uncommonly  met  with  even  in  cases  which 
show  few  other  manifestations  of  the  disease.  Bands  of  white 
fibrous  tissue  are  seen  running  through  the  characteristic 
slightly  brownish  tinged,  soft  testicular  substance. 

Tumours. — Sarcoma  is  the  commonest  tumour  of  the 
testicle.  It  is  often  of  the  large  round  cell  type,  and  in  appear- 
ance (owing  to  accompanying  necrosis)  sometimes  resembles 
a  gumma.  Such  tumours  are  rarely  seen  in  the  post-mortem 
room,  but  the  recurrences  in  the  retroperitoneal  glands  may 
be  met.  Such  recurrent  sarcomata  may  attain  a  large  size. 

DISEASES  OF   THE  PEOSTATE 

Hypertrophy. — Simple  enlargement  of  the  prostate  is  a 
common  condition  in  men  of  sixty  years  of  age  and  upwards. 
It  leads  to  obstruction  of  the  urethra  and  to  dilatation  and 
hypertrophy  of  the  bladder.  A  fibrous  and  a  glandular 
variety  are  distinguished,  the  former  being  hard  and  the  latter 
soft. 

Microscopically,  sections  show  the  structure  of  the  normal 
prostate-gland  spaces  and  intervening  fibre-muscular  tissues. 
In  some  cases  the  former,  in  others  the  latter,  predominate. 

Corpora  amylacea  are  commonly  present  in  the  gland  spaces 
in  this  condition.  They  are  produced  by  a  transformation 
occurring  in  desquamated  epithelial  cells  and  appear  as  rounded 
or  oval  bodies  showing  concentric  lamination  not  unlike  starch 
grains. 

Acute  Prostatitis,  with  abscess  formation,  is  occasionally 
met  with  following  the  formation  of  a  false  passage  in  cathe- 
terisation  of  the  urinary  bladder. 

Tumours. — Carcinoma  of  the  prostate  is  the  commonest 
tumour.  It  has  a  special  tendency  to  show  secondary 
deposits  in  bone.  The  types  met  with  are :  columnar-celled, 
scirrhous,  and  encephaloid. 


CHAPTER   XIV 

TUMOURS 

TUMOURS  may  be  primarily  divided  into  (i)  Simple  and  (2) 
Malignant.  There  is  actually  no  very  hard  and  fast  line 
between  the  two  varieties,  certain  tumours  being  less  malig- 
nant than  others.  Moreover,  a  simple  tumour  may  become 
malignant.  On  the  whole,  however,  the  distinction  is  suffi- 
ciently well  marked  to  serve  as  a  basis  for  classification. 

The  main  morphological  difference  between  the  two  types 
is  that  the  simple  tumour  is  encapsuled,  i.e.  is  more  or  less 
sharply  defined  from  the  tissues  in  its  immediate  neighbour- 
hood, while  the  malignant  tumour  infiltrates  surrounding 
tissues  and  erodes  structures  such  as  blood-vessels.  The 
tendency  to  recur  when  removed,  and  to  produce  metastases 
or  secondary  growths,  both  characters  belonging  to  malignant 
tumours,  are  explained  by  this  character  of  infiltration. 

In  deciding  in  a  given  instance  whether  a  tumour  is  simple 
or  malignant,  certain  points  should  be  attended  to. 

1.  Position. — Tumours    of    the    intestine    are   usually 
malignant,  while  in  the  case  of  the  uterus  the  commonest 
tumour  is  the  simple  myoma. 

2.  Size. — On  the  whole  a  large  tumour  is  more  likely  to 
be  malignant  than  a  small  one,  although  there  are  notable 
exceptions  to  this. 

3.  Ulcer ation. — An  ulcerating  tumour  is  much  more  likely 
to  be  malignant  than  simple. 

275 


276  TUMOURS 

4.  Necrosis. — Necrotic  changes  are  more  frequently  met 
with  in  malignant  growths,  owing  to  their  tendency  to  over- 
grow their  blood-supply  and  from  other  causes. 

5.  Hcemorrhage  is  much  more  frequently  met  with  around 
and  in  malignant  growths,  owing  to  their  capacity  to  erode 
blood-vessels,  and  owing  to  the  fact  that  their  own  blood- 
vessels are  thin  walled  and  badly  supported. 

6.  Infiltration  of  the  surrounding  parts,  as  already  in- 
dicated, is  characteristic  of  malignant  growths,  while  the 
simple  tumour  is,  as  a  rule,  well  defined. 

7.  Occurrence   of  Metastases.  —  If   such  are  present  the 
tumour  is  malignant.    It  should  be  borne  in  mind,  however, 
that  simple  tumours,  such  as  the  myoma  of  the  uterus,  may 
be  multiple. 

Microscopic  points  of  distinction  between  the  two  groups 
are  as  follows  : 

1.  Resemblance  to  Homologous  Normal   Tissue. — This   is 
much   more   characteristic   of   simple   growths.    Malignant 
growths  deviate  more  or  less  markedly  from  the  normal 
tissues  which  they  represent.    They  tend  to  resemble  more 
closely  the  embryonic  equivalent  of  the  tissue. 

2.  Character  of  Cells. — The  cells  of  malignant  growths 
tend  to  be  larger  and  to  vary  in  size  and  shape.    Their  nuclei 
also  are  larger  and  often  multiple.    Mitotic  figures  are  fre- 
quently numerous   in    malignant   growths   and  may  show 
aberrant  types,  such  as  multipolar  division. 

3.  Infiltration  of   surrounding  tissues  is  again  a  micro- 
scopic character  of  malignant  growths,  while  simple  tumours 
are  encapsuled .    Associated  with  this  character  is  the  tendency 
to  erode  blood-vessels  and  other  normal  structures. 

4.  Inflammatory  changes  in  the  tissues  around  are  found  in 
connection  with  malignant  growths,  while  simple  tumours 
excite  little  reaction. 

5.  Necrosis  is  again  more  characteristic  of  the  malignant 
type  than  of  the  simple. 


SIMPLE  TUMOURS  277 

6.  Hemorrhage  more  or  less  extensive  is  very  characteristic 
of  malignant  growths  and  is  due  as  a  rule  to  escape  of  red 
blood  cells  from  thin-walled,  imperfectly-developed  blood- 
vessels, but  may  also  be  due  to  erosion  of  vessels  by  cancer 
cells. 

7.  Relation  of  epithelial  cells  to   stroma.  —  In  glandular 
tumours  of  the  simple  type  a  basement  membrane  is  usually 
present.     In  malignant  growths  this  is  absent. 

In  the  following  description  of  the  common  tumour 
formations  no  elaborate  system  of  classification  is  adopted. 
Any  such  system  of  classification  must  of  necessity  be  tentative, 
pending  the  discovery  of  the  cause  of  tumour  growth. 
Further,  exceptions  to  rules  are  so  frequently  met  with  in 
relation  to  neoplasms  that  the  most  elaborate  system  breaks 
down  at  many  points  unless  each  tumour  be  placed  in  a 
category  by  itself. 


A.  SIMPLE   TUMOURS 

Tumours  composed  of  Fibrous  Tissue 

Fibroma. — This  is  a  tumour  composed  of  connective 
tissue  cells  and  fibres.  Two  types,  soft  and  hard,  are 
distinguished,  according  as  the  cells  or  the  fibres  pre- 
dominate. 

Sites. — They  may  arise  anywhere  where  there  is  connective 
tissue, — cutis,  fascia,  periosteum,  dura  mater,  submucous 
tissue,  pharynx  and  nose  (polypi).  They  are  also  common 
as  minute  growths  in  the  medulla  of  the  kidney.  Sometimes 
they  occur  in  connection  with  scars  (cheloids).  A  special 
type,  the  neurofibroma,  occurs  in  relation  to  nerves. 

Appearance. — Usually  a  well-defined  rounded  or  lobulated 
and  encapsuled  nodule,  soft  or  hard,  firm  in  consistence,  pink 
or  white,  the  softer  type  tending  to  be  pink  from  its  greater 
vascularity.  The  cut  surface  sometimes  has  a  watered  silk 


278  TUMOURS 

appearance.    Degenerative  changes,  such  as  myxomatous, 
cedematous,  calcareous,  are  sometimes  met  with. 

Microscopically^  the  appearances  are  those  of  ordinary 
connective  tissue.  Sometimes  the  cells  predominate,  at  other 
times  the  intercellular  material,  according  as  the  tumour  is  of 
the  hard  or  soft  variety.  The  cells  are  usually  spindle-shaped, 
but  in  the  more  cellular  types  may  be  rounded.  The  inter- 
cellular material  consists  of  wavy  collagenous  fibres,  staining 
deep  red  with  eosin  and  with  acid  fuchsin. 


Tumours  composed  of  Myxomatous  Tissue 

Myxoma. — This  is  a  somewhat  rare  tumour  composed  of 
mucoid  or  myxomatous  tissue,  an  embryonic  form  of  con- 
nective tissue.  The  umbilical  cord  is  largely  composed  of 
such  tissue.  Certain  connective  tissue  tumours — fibromata, 
fibro-myomata,  chondromata — are  not  infrequently  in  part 
composed  of  myxomatous  tissue.  When  occurring  in  relation 
to  tumours  composed  of  more  adult  tissue,  the  change  is 
regarded  as  a  degenerative  one. 

Sites. — Such  tumours  may  be  found  in  any  of  the  sites  in 
which  fibromata  occur ;  most  commonly  in  subcutaneous 
and  submucous  tissue.  Not  infrequently  such  growths 
show  a  tendency  to  diffuse  themselves  and  invade  surrounding 
structures ;  such  are  to  be  regarded  as  sarcomata.  The 
placental  or  hydatid  mole  is  often  classified  as  a  myxoma 
(myxoma  of  the  chorion,  p.  268). 

Appearance. — Very  soft  and  gelatinous,  not  infrequently 
the  material  when  manipulated  forming  long  strings.  Trans- 
lucent, sometimes  with  minute  haemorrhages. 

Microscopically,  the  growth  is  found  to  be  made  up  of 
rounded,  spindle-shaped  and  branching  cells,  widely  separated 
from  one  another.  The  material  between  the  cells  is  homo- 
geneous or  slightly  fibrillated,  and  usually  stains  very  faintly. 
Vessels  are  of  course  present  and  haemorrhages  may  be  found. 


SIMPLE  TUMOURS  279 

Tumours  composed  of  Fatty  Tissue 

Lipoma. — Sites. — Subcutaneous  tissue,  especially  parts 
liable  to  pressure,  e.g.  shoulders,  buttocks,  wall  of  large 
bowel,  kidney,  rarely  brain. 

Appearance. — Such  tumours  vary  much  in  size,  may  be 
very  minute,  occasionally  very  large,  are  usually  lobulated, 
and  resemble  fatty  tissue. 

Microscopical fy,  they  consist  of  adipose  tissue  with  bands  of 
supporting  fibrous  tissue  carrying  blood-vessels.  All  stages  in 
development  of  fat  cell  are  found  from  fibrous  tissue  cell,  with 
minute  globule  of  fat,  up  to  cell  with  merely  thin  rim  of  proto- 
plasm and  nucleus  pressed  aside  by  large  fat  globule.  Crystals 
of  fatty  acids  are  often  present  in  the  cells. 

Tumours  composed  of  Cartilage 

Chondroma. — A  tumour  composed  of  cartilage  either 
hyaline  or  fibre-cartilage. 

Sites. — It  is  occasionally  found  growing  from  cartilage  of 
rib  or  larynx  (ecchondroma)  more  usually  in  relation  to 
bone  or  in  the  interior  of  glands  such  as  parotid,  testicle 
(enchondroma).  One  of  the  commonest  sites  is  the  perios- 
teum of  long  bones,  especially  at  the  ends  of  the  metacarpals 
and  phalanges. 

Appearance. — It  is  a  rounded  or  lobulated  tumour,  firm 
and  elastic,  surrounded  with  a  fibrous  capsule  which  sends 
in  trabeculae  between  the  lobules.  Not  infrequently  it  shows 
calcification  or  soft  areas  of  myxomatous  degeneration. 

Microscopically,  the  tumour  is  found  to  consist  of  lobules  of 
cartilaginous  material  composed  of  rounded  or  branched 
cartilage  cells  lying  in  spaces  between  which  is  a  matrix, 
sometimes  homogeneous,  at  other  times  fibrillated,  occasionally 
myxometous.  Calcified  areas  which  take  on  the  haematoxylin 
stain  deeply  are  not  infrequently  met  with.  The  tumour  is 
surrounded  with  a  connective  tissue  capsule  carrying  blood- 
vessels, prolongations  of  which  dip  down  between  the  lobules. 


280  TUMOURS 

Tumours  composed  of  Bone 

Osteoma. — Two  varieties  are  distinguished  :  (i)  the  com- 
pact or  eburnated  ivory  exostosis  found  in  connection  with 
the  bones  of  the  skull ;  (2)  the  spongy  osteoma,  in  which  the 
bony  trabeculae  are  thinner  and  more  widely  separated. 
The  exostoses  found  in  connection  with  the  attachment  of 
muscles  are  probably  not  true  tumours.  They  are  more  of 
the  nature  of  hypertrophies  of  bony  tissue,  i.e.  ossification 
following  trauma  or  irritation. 

Tumours  composed  of  Muscle 

Myoma. — Two  varieties  are  distinguished  :  (i)  the  rhabdo- 
myoma  or  tumour  composed  of  striped  muscle  fibres,  which 
is  very  rare,  usually  congenital  and  commonly  malignant 
(sarcomatous).  It  is  found  in  the  kidney  and  testicle,  and  is 
due  to  inclusion  of  portions  of  the  lumbar  muscles.  (2) 
Leiomyoma,  a  very  common  tumour  composed  of  non-striped 
muscle  fibres. 

Sites. — Leiomyomata  are  found  by  far  most  frequently 
growing  in  the  wall  of  the  uterus.  They  may  also  occur 
in  other  positions  where  non-striped  muscle  is  found,  such  as 
the  alimentary  tract,  more  especially  the  oesophagus,  also 
bladder  and  prostate. 

Appearance. — In  the  uterus  the  tumours  are  frequently 
multiple.  They  vary  greatly  in  size,  from  something  just 
visible  by  the  unaided  eye  to  a  tumour  the  size  of  a  foetal 
head.  They  are  most  frequent  in  the  body  of  the  uterus 
but  also  occur  in  the  cervix. 

Three  varieties  are  distinguished  according  to  the  position 
in  the  uterine  wall,  viz.  (i)  intramural ;  (2)  subserous,  when 
projecting  into  the  peritoneal  cavity  and  covered  with  peri- 
toneum over  the  greater  part  of  its  surface ;  (3)  submucous, 
when  projecting  into  the  cavity  of  the  uterus  (Fig.  104). 


SIMPLE  TUMOURS  281 

The  tumours  are  rounded  and  well  defined  from  the 
neighbouring  muscle.  On  the  cut  surface  they  are  usually 
pink  in  colour  and  show  an  appearance  like  watered  silk 
or  balls  of  cotton.  Degenerative  changes  are  common  in 
myomata,  e.g.  myxomatous  change,  calcification  and  a 
necrotic  change  known  as  "  red  softening." 

Microscopic  Appearance. — The  tumour  does  not  differ  in 
any  essential  respect  from  the  normal  uterine-wall  tissue.  It  is 
composed  of  bundles  of  (i)  non- striped  muscle  fibres  running 
in  all  directions  and  therefore  in  sections  cut  sometimes  longi- 
tudinally, sometimes  obliquely,  sometimes  transversely ;  (2) 
fibrous  tissue  running  between  the  bundles  and  between  the 
individual  fibres.  So  markedly  does  this  fibrous  element 
enter  into  the  composition  of  the  tumour  that  the  term  "  fibro- 
myoma  "  is  often  employed.  In  the  myomata  found  in  the 
oesophagus  the  amount  of  fibrous  tissue  is  much  less.  The 
individual  muscle  fibres  when  cut  longitudinally  are  elongated, 
often  sinuous  structures  with  similarly  elongated  nuclei.  The 
fibrous  tissue  often  shows  degenerative  changes :  (i)myxomatous, 
(2)  hyaline,  (3)  calcareous.  Blood-vessels  with  well-developed 
walls  are  always  present.  Sometimes  gland  acini  are  scattered 
through  the  fibro-muscular  tumour  (adeno-myoma). 

Tumours  composed  of  Vascular  Tissue 

Angioma. — Two  primary  varieties  may  be  distinguished, 
viz.  (i)  hsemangioma,  (2)  lymphangioma ;  a  further  sub- 
division of  each  variety  into  (a)  plexiform  or  capillary,  and 
(b)  cavernous  may  be  made. 

Sites  and  Appearance. — Hcemangiomata  are  most  usually 
found  in  relation  to  skin  or  mucous  membrane.  They  may 
be  merely  areas  of  purple  colour,  the  so-called  "  port  wine 
stains,"  or  they  may  project  and  may  even  be  pendulous. 
They  are  always  dark  red  in  colour  and  are  often  pulsatile. 
These  cutaneous  angiomata  most  usually  belong  to  the  plexi- 
form variety,  but  may  be  cavernous.  The  cavernous  type  is 
most  common  in  the  liver,  but  may  occur  in  relation  to  the 


282  TUMOURS 

membranes  of  the  brain  and  in  the  skin.  It  appears  as  a 
dark  purple  area,  more  or  less  wedge  shaped,  immediately 
under  the  capsule  of  the  organ  (Fig.  76).  The  condition  is 
much  more  common  in  the  ox  than  in  man.  Lymphangiomata 
are  found  in  relation  to  skin  and  tongue.  They  are  probably 
always  congenital  and  mostly  belong  to  the  cavernous  type. 

Microscopic  Appearances. — ( i )  Capillary Angioma. — Instead 
of  the  dense  fibrous  tissue  of  the  cutis,  great  numbers  of 
minute  spaces  lined  with  fairly  large  endothelial  cells  are 
found.  Some  of  these  spaces  contain  blood,  others  are  empty. 
Between  the  capillaries  there  is  more  or  less  loose  connective 
tissue. 

(2)  Cavernous  Angioma. — In  this  type,  large  spaces  are 
found  lined  with  spindle-shaped  endothelial  cells  and  filled  with 
blood,  sometimes  with  thrombi.  The  walls  of  the  spaces  are 
formed  of  well-developed  fibrous  tissue. 

Tumours  composed  of  Lymphoid  Tissue 

Lymphoma. — A  simple  lymphoma  is  a  rare  tumour,  usually 
small  and  solitary.  Microscopically,  it  has  the  appearance 
of  normal  lymphoid  tissue,  having  a  capsule,  a  reticulum  in 
which  are  large  numbers  of  lymphocytes  also  endothelial 
cells.  The  condition  is  very  difficult  to  distinguish  from 
mere  hypertrophy  of  lymphoid  tissue.  The  malignant  type, 
lymphosarcoma,  is  more  common  and  much  more  important. 

Tumours  composed  of  Neuroglia 

G-lioma.  —  Such  tumours,  arising  as  they  do  from  the 
neuroblast,  are  epiblastic  in  origin. 

Sites. — They  are  found  in  the  brain,  retina  and  spinal 
cord. 

Appearance. — As  a  rule  they  are  not  well  defined,  but 
merge  into  the  surrounding  brain  substance.  They  vary 
much  in  size,  may  be  opaque  or  translucent,  white  or  pink. 


SIMPLE  TUMOURS  283 

A  slow-growing,  simple  type  is  recognised,  but  many  of  them 
have  the  characters  of  malignant  growths  and  may  be  called 
glio-sarcomata  (see  p.  243).  Haemorrhages  frequently  occur 
into  their  substance. 

Microscopically ',  such  tumours  are  formed  of  small  round  cells 
with  branching  prolongations  (spider  cells),  the  latter  forming  a 
felted  mesh  work  between  the  cells.  In  the  case  of  the  retinal 
glioma,  the  branching  processes  may  be  absent.  Vessels  are 
present  which  are  often  thin  walled  and  may  rupture,  leading 
to  haemorrhages. 

Epithelial  Tumours 

Such  tumours,  in  addition  to  their  epithelial  elements, 
always  possess  a  greater  or  smaller  amount  of  supporting 
fibrous  tissue  stroma. 

i.  Papilloma. — This  is  a  tumour  projecting  from  an  epi- 
thelium-covered surface,  composed  of  connective  tissue  and 
epithelial  cells.  Two  types,  (a)  squamous  papilloma  and  (b) 
mucous  papilloma,  may  be  distinguished  according  to  the 
type  of  epithelial  surface  from  which  the  tumour  grows. 

(a)  Squamous  papillomata. — Sites. — These  are  found  in 
relation  to  skin,  mouth,  larynx,  pharynx,  oesophagus  or 
vagina. 

Appearance. — They  consist  of  a  series  of  projections  com- 
posed of  a  connective  tissue  core  carrying  blood-vessels  and 
a  covering  of  squamous  epithelium.  The  epithelium  is 
frequently  much  thickened  and  the  dead  material  tends 
to  accumulate  between  the  prolongations.  The  skin 
papilloma  or  ordinary  wart  is  sometimes  congenital.  It  is 
commonest  in  childhood  and  is  often  infective,  being  prob- 
ably due  to  some  micro-organism.  One  of  the  infective 
papillomata,  the  venereal  wart,  is  found  in  relation  to  the 
genitals.  Some  are  due  to  the  irritation  of  chemicals,  such 
as  paraffin.  Molluscum  contagiosum  is  a  condition  appearing 
as  small  red  elevations,  affecting  more  especially  the  skin 


284  TUMOURS 

of  the  head,  face  and  hands.  The  elevations  break  down 
in  the  centre  and  discharge  a  cheesy  material.  The  disease  is 
regarded  as  being  due  to  some  germ  not  yet  discovered. 

Microscopic  Appearances. — The  connective  tissue  core  con- 
taining vessels  is  seen  in  places  in  connection  with  the  cutis. 
In  other  places  there  are  isolated  rounded  areas  of  fibrous 
tissue  produced  by  the  cutting  transversely  of  one  of  the  finger- 
like  processes.  Upon  this  connective  tissue  is  placed  the 
epithelium  which  corresponds  to  the  stratified  epithelium  of 
the  skin  and  like  it  shows  differentiation  into  layers.  The 
epithelium  shows  a  sharp  line  of  demarkation  from  the 
subjacent  connective  tissue.  Occasionally  whorl-like  masses 
of  cornified  epithelium  are  seen  simulating  the  "  cell-nests  "  of 
cancers,  but  these  are  buried  in  the  thick  layer  of  epithelium 
and  do  not  penetrate  the  fibrous  stroma. 

(b)  Mucous  papillomata. — Sites. — These  may  grow  from 
any  mucous  membrane — alimentary  canal,  bile  ducts,  bladder, 
pelvis  of  kidney.  Some  of  these  are  undoubtedly  due  to 
organisms,  viz.  the  condition  known  as  coccidiosis,  which 
is  a  papillomatous  condition  of  the  bile  ducts,  found  specially 
in  the  rabbit,  due  to  a  protozoon — the  coccidium  oviforme. 
A  somewhat  similar  condition  in  the  stomach  of  the  rat  is 
due  to  the  presence  of  a  small  nematode. 

Appearance. — In  structure  the  mucous  papilloma  consists 
of  a  slender  connective  tissue  core  carrying  blood-vessels, 
and  covered  by  a  layer  of  epithelium  which  may  be  columnar, 
cubical  or  transitional,  according  to  the  site.  One  of  the 
commonest  sites  for  this  type  is  the  bladder,  where  the  growth 
consists  of  numerous  delicate  processes  forming  a  sea-anemone- 
like  mass. 

Microscopic  Appearances.  —  A  connective  tissue  core  of 
great  delicacy,  carrying  blood-vessels,  dividing  and  again 
dividing,  is  seen  in  connection  with  the  submucous  coat  of  the 
viscus  if  the  section  be  accurately  through  the  root  of  the 
tumour.  Many  of  the  branches  are,  however,  cut  transversely. 
Upon  this  connective  tissue  core  is  placed  the  epithelium 


SIMPLE  TUMOURS  285 

which  may  be  transitional  (in  the  case  of  the  bladder)  show- 
ing numerous  layers  of  elongated  epithelial  cells  tending  to 
become  loosened  and  to  separate  in  the  more  superficial 
layers.  In  the  case  of  the  intestinal  and  bile  duct  papilloma 
the  epithelial  cells  are  columnar.  Mitotic  figures  are  often 
numerous  in  the  cells  of  the  villous  papilloma  of  the  bladder. 

2.  Adenoma  is  the  term  applied  to  a  simple  tumour  com- 
posed of  gland  elements.  Such  tumours  contain,  in  addition 
to  the  epithelial  gland  cells,  a  larger  or  smaller  amount  of 
supporting  fibrous  tissue.  In  this  connective  tissue  the 
nutrient  vessels  run.  When  the  fibrous  tissue  is  large  in 
amount,  the  term  fibro-adenoma  is  used.  Often  the  gland 
acini  in  the  tumour  become  dilated  (cystic  adenoma). 
Occasionally  (breast  and  ovarian  adenomata)  within  the 
cysts  there  is  a  papillomatous  development  of  the  epithelial 
elements  supported  by  fibrous  tissue  (papilliferous  cystic 
adenoma).  Such  tumours  are  generally  regarded  as  being  of 
doubtful  simplicity. 

Sites. — Any  gland  may  be  the  site  of  origin  of  an  adenoma. 
The  commonest  site  for  such  tumours  is  undoubtedly  the 
mammary  gland.  The  prostate,  thyroid,  liver  and  other 
glands  may  be  the  seats  of  similar  tumours. 

Appearance.  —  Such  tumours  are  round  or  lobulated, 
vary  much  in  size,  and  are  surrounded  by  a  fibrous  capsule 
so  that  they  are  readily  shelled  out.  The  colour  is  white  or 
pink,  and  on  section  minute  clear  foci  representing  groups 
of  gland  acini  may  be  seen.  Cysts  are  often  present. 
Another  common  site  for  adenomata  is  the  ovary,  forming 
the  so-called  compound  cystic  adenoma.  The  cysts  are 
often  very  large  and  contain  mucinous  material. 

Microscopically,  the  essential  parts  of  the  tumour  are  (i) 
gland  acini  lined  with  epithelium,  resembling  that  of  the  gland 
from  which  the  tumour  arises,  set  upon  a  basement  membrane. 
Secretion  may  be  present,  colloid  material  in  the  case  of 
tumours  of  the  thyroid  gland,  mucinous  material  in  the 


286  TUMOURS 

compound  cystic  ovarian  tumour.  The  acini  are  not  in- 
frequently dilated,  forming  cysts  of  various  size.  Intracystic 
papillomatous  projections  also  covered  with  epithelium  may  be 
found,  and  in  the  case  of  the  breast  tumours  small  rounded 
masses  of  fibrous  tissue,  the  so-called  intracanalicular  fibromata. 
The  epithelium  in  the  case  of  the  ovarian  tumours  is  markedly 
columnar  in  type. 

(2)  Fibrous  supporting  tissue,  which  varies  much  in  amount, 
sometimes,  in  the  case  of  the  fibro-adenomata,  occurring  in 
large  bands  which  separate  the  groups  of  gland  acini  widely 
from  one  another.  Running  in  this  connective  tissue  stroma 
are  the  blood-vessels  of  the  tumour,  as  a  rule,  well  developed. 

B.  MALIGNANT  TUMOURS 

The  general  characters  of  malignant  growths  and  the 
points  wherein  they  differ  from  the  simple  tumour  have 
already  been  discussed.  The  chief  characteristic  of  such 
growths  is  the  tendency  to  invade  normal  structures,  so  that 
they  infiltrate  the  tissues  in  which  they  arise  and  tend  to 
erode  blood-  and  lymph-vessels,  and  to  pass  by  these  in  the 
form  of  tumour  emboli  to  other  parts  of  the  body. 

The  term  cancer  is  sometimes  used  generically  for  such 
growths,  but  the  pathologist  usually  reserves  that  term  for 
the  epithelial  type  of  malignant  growth. 

Microscopically,  the  malignant  tumour  is  characterised  by 
an  imperfect  repetition  of  the  normal  tissues.  Whereas  the 
simple  growth  resembles,  in  many  cases  very  closely,  the 
normal  adult  tissue  from  which  it  arises,  the  malignant  tumour 
shows  considerable  deviation  from  the  homologous  normal 
tissue.  It  tends  to  resemble  in  many  instances  the  embryonic 
type  of  the  tissue.  Hence  the  use  of  the  term  "  atypical  "  in 
relation  to  them. 

Just  as  simple  tumours  may  be  divided  primarily  into  (i) 
those  arising  from  and  composed  of  connective  tissue  and  (2) 
those  arising  from  and  partly  composed  of  epithelial  tissue, 
so  in  the  case  of  the  malignant  growths  we  may  distinguish 


MALIGNANT  TUMOURS  287 

a  connective  tissue  and  an  epithelial  group.    The  former 
are  sarcomata,  the  latter  carcinomata  or  true  cancers. 


SARCOMATA 

These  are  tumours  which  are  essentially  cellular,  i.e. 
contain  a  minimal  amount  of  intercellular  material.  The  cells 
are  of  the  connective  tissue  type  and  are  embryonic,  i.e. 
imperfectly  differentiated.  So  that  what  appears  to  be  the 
most  advanced  stage  of  development  of  which  the  tumour 
cells  are  capable  corresponds  with  an  early  stage  in  the 
development  of  a  fibrous  tissue  cell  from  the  primitive  round 
connective  tissue  corpuscle. 

Under  normal  circumstances,  either  during  development 
or  in  the  course  of  the  laying  down  of  new  tissue  in  the 
process  of  healing,  the  connective  tissue  corpuscle  passes 
from  a  'small  round  cell  with  small  round,  relatively  large, 
nucleus  and  small  amount  of  protoplasm  to  the  large  round 
cell  with  abundant  protoplasm.  The  cell  then  becomes  oval 
and  eventually  spindle  shaped.  Subsequently  from  the 
protoplasm  there  are  split  off  collagenous  fibrils  which  form 
the  intercellular  material. 

In  this  type  of  growth  the  cell  which  has  taken  on  tumour 
characters  may  stop  at  any  one  of  these  stages  and  subse- 
quently reproduce  cells  of  a  similar  stage  of  development 
and  no  other  type.  Seldom  does  it  occur  that  the  fully- 
developed  type  of  connective  tissue  cell  is  found  in  the 
sarcomata.  It  is  usually  the  more  primitive  types  which  are 
found.  Occasionally  a  tumour  which  shows  a  high  degree 
of  differentiation  may  on  recurring  exhibit  a  differentiation 
of  a  less  high  degree.  Thus  a  tumour  with  the  characters  of 
a  fibroma  may  on  recurring  (recurrent  fibroid)  assume  the 
characters  of  a  sarcoma. 

As  the  name  sarcoma  indicates,  such  tumours  are  flesh- 
like.  As  a  rule  they  form  large  masses  of  opaque  white  or 


288  TUMOURS 

faintly  pink  material.  Necrotic  areas  are  not  infrequently 
present,  and  haemorrhages  are  very  common.  Certain  types 
are  very  vascular  (angiosarcomata)  and  some  develop  pig- 
ment (melanotic  sarcomata). 

In  consistence  sarcomata  are  commonly  soft,  sometimes 
diffluent,  and  often  show  areas  of  more  marked  softening. 
They  are,  however,  sometimes  firm  and  may  even  be  hard. 
Like  other  forms  of  malignant  growth,  they  show  a  marked 
tendency  to  infiltrate  and  thus  are  seldom  encapsuled. 

Although,  as  already  stated,  they  tend  to  stop  short  of  the 
fully-developed  form  of  the  connective  tissue  from  which 
they  arise,  such  tumours  not  infrequently  reach  a  fair  degree 
of  differentiation  of  tissue.  Thus  those  arising  from  cartilage 
tend  to  produce  cartilage,  those  arising  from  bone  produce 
bone-like  tissue,  those  arising  from  muscle  may  produce 
muscle  cells,  and  so  on.  This  differentiation  forms  a  basis 
for  classification.  Hence  we  speak  of  chondro-sarcomata, 
osteo-sarcomata,  etc.  A  majority  of  these  tumours,  however, 
merely  exhibit  the  various  stages  of  development  of  the 
connective  tissue  cell.  In  order  to  classify  them  we  use  such 
terms  as  small  round  cell  sarcoma,  large  round  cell  sarcoma, 
small  spindle  cell  sarcoma,  large  spindle  cell,  fibre-sarcoma, 
mixed  cell  sarcoma. 

As  a  rule,  the  less  differentiated  the  type  of  cell  composing 
the  tumour  the  more  malignant  it  is.  Thus  the  small  round 
cell  sarcoma  is  one  of  the  most  malignant  types.  Sometimes 
a  tumour  starts  by  being  simple  but  becomes  malignant, 
either  a  portion  of  the  growth  assuming  the  malignant  type, 
or  the  whole  tumour,  as  in  the  so-called  recurrent  fibroid, 
becoming  more  and  more  malignant  at  each  recurrence.  This 
prepares  one  for  the  fact  that  there  are  degrees  of  malignancy. 

Sarcomata  very  commonly  produce  metastases.  Such 
metastatic  growths  are  found  not  so  frequently  in  lymph 
glands  as  in  the  internal  organs.  Hence  the  statement  that 
these  tumours  spread  more  by  the  blood  than  by  the  lymph 


MALIGNANT  TUMOURS  289 

channels.  This  is  true  up  to  a  certain  point ;  but  there  are 
exceptions,  particularly  in  the  case  of  the  melanotic  tumour 
which  often  spreads  by  the  lymphatics. 

As  regards  sites  of  origin,  such  growths  may  arise  in  any 
part  of  the  body  in  which  connective  tissue  is  found,  and  this 
means  anywhere  at  all.  There  are,  however,  certain  parts 
and  tissues  more  commonly  affected  than  others.  Thus, 
subcutaneous  tissue,  intermuscular  septa,  fasciae,  perios- 
teum, bone,  lymph  glands  are  common  sites  of  origin.  As 
regards  the  secondary  deposits,  these  occur  more  commonly 
in  the  lung  than  in  any  other  organ  (see  p.  148). 

Types  of  Sarcomata 

Small  Round -Cell  Sarcoma. — This  is  a  white,  grey  or 
pink,  soft,  sometimes  diffluent  tumour,  found  primarily  in 
connection  with  subcutaneous  tissue,  bone,  muscles,  brain 
testicle,  and  secondarily  anywhere,  but  most  commonly  in  the 
lungs.  Haemorrhages  and  areas  of  necrosis  are  frequent. 
The  tumour  is  one  of  the  most  malignant  types  known. 

Microscopically,  such  tumours  are  composed  of  small  round 
cells  closely  packed,  with  scanty  protoplasm  and  small  dark- 
staining  nuclei.  The  cells  resemble  very  closely  the  lympho- 
cyte of  the  blood  and  lymph  glands.  The  intercellular 
material  is  scanty,  granular  or  slightly  fibrillated.  The  vessels 
are  thin  walled,  often  consisting  of  a  single  layer  of  cells. 
Haemorrhages  and  areas  of  necrosis  are  frequent. 

The  so-called  Lymphosarcoma  may  be  regarded  as  a  sub- 
variety  of  the  above.  It  originates  in  lymphoid  tissue, 
very  commonly  the  lymphatic  glands  of  the  mediastinum, 
and  is  very  malignant.  In  appearance  it  resembles  other 
types  of  sarcoma  (Fig.  56). 

Microscopically,  such  tumours  are  composed  in  large  part  of 
small  round  lymphocyte-like  cells  with  rather  more  intercellular 
material  than  in  the  case  of  the  ordinary  type  of  small  round- 

19 


290  TUMOURS 

cell  sarcoma.  There  is  often  a  fair  number  of  larger  flattened 
or  polygonal  cells,  representing  the  endothelial  elements  of 
lymphoid  tissue.  Occasionally  this  larger  type  of  cell  is  the 
predominant  one  (endothelioma). 

Large  Round-Cell  Sarcoma. — These  tumours  have  much 
the  same  appearance  as  the  above,  but  tend  to  be  on  the 
whole  firmer  in  consistence.  The  sites  of  origin  are  also 
much  the  same,  but  the  testicle,  pharynx  and  posterior  nares 
and  muscle  are  perhaps  more  commonly  affected. 

Microscopically,  as  in  the  previous  type,  the  tumour  is 
composed  essentially  of  cells,  but  there  is  more  intercellular 
material,  and  the  fibrils  of  which  it  is  composed  are  thicker. 
The  cells  are  of  course  larger,  rounded  or  polygonal,  with 
more  abundant  protoplasm  and  a  nucleus  with  a  wider-meshed 
network,  hence  staining  less  deeply.  Areas  of  necrosis  and 
haemorrhages  are  common.  The  vessels  are  better  developed. 
Sometimes  the  cells  have  an  alveolar  arrangement. 

Small  Spindle -Cell  Sarcoma. — Such  tumours  resemble 
the  preceding  but  are  more  benign. 

Microscopically,  the  tumour  is  composed  of  small  oat-shaped 
cells  arranged  irregularly  in  bundles.  The  cells  represent  a 
further  stage  in  the  development  of  the  connective  tissue 
corpuscle.  The  vessels  are,  however,  still  very  imperfectly 
formed. 

Large  Spindle -Cell  Sarcoma. — In  this  type  the  fas- 
ciculation  may  be  visible  to  the  naked  eye.  The  tumour 
bears  considerable  resemblance  to  .a  fibroma.  It  is,  more- 
over, firmer  than  most  other  types.  Such  tumours  occur  in 
relation  to  periosteum,  muscles,  mamma,  or  ovary. 

Microscopically,  the  cells  are  arranged  in  bundles.  There 
is  a  considerable  amount  of  intercellular  fibrillated  material, 
and  the  vessels  are  fairly  well  supported.  It  is  difficult  in 
many  instances  to  differentiate  such  growths  from  cellular 
fibromata.  The  cells  tend,  however,  to  be  larger  and  to  vary 
more  in  size,  and  mitotic  figures  are  often  present. 


MALIGNANT  TUMOURS  291 

From  the  microscopic  point  of  view  it  is  a  matter  of  great 
difficulty  in  many  instances,  especially  when  only  a  minute 
portion  of  tissue  is  available,  to  differentiate  such  tumours 
from  granulation  tissue.  Nothing  less  than  long  experience 
will  enable  the  pathologist  to  do  this  in  many  cases.  The 
point  to  attend  to  is  :  the  uniformity  of  type  in  the  cells. 
In  the  case  of  granulation  tissue  all  stages  of  development  of 
the  fibrous  tissue  cell  will  be  met  with,  whereas  in  the  case 
of  the  sarcoma  the  cells  tend  to  be  all  of  one  type,  round  or 
spindle,  as  the  case  may  be. 

Mixed  Cell  Sarcomata  are  met  with  occasionally.  In 
such,  in  addition  to  round  and  spindle  cells,  giant  cells 
(multinucleated  masses  of  protoplasm)  are  often  found. 

To  this  type  belongs  the  myeloid  or  giant  cell  sarcoma 
found  in  relation  to  bone. 

Sites. — Such  tumours  occur  in  young  subjects,  chiefly  in 
the  upper  end  of  the  tibia  and  fibula,  the  lower  end  of  the 
femur  and  in  the  lower  jaw  (malignant  epulis,  Fig.  109). 

Appearance. — These  tumours  are  slow  growing  and  show 
generally  a  low  degree  of  malignancy.  They  do  not  tend  to 
produce  metastasis  and  rarely  recur  when  removed.  They 
grow  from  the  interior  of  the  bone,  distending  and  thinning 
the  overlying  bony  tissue.  They  show  the  appearances  of 
sarcomata  generally,  but  haemorrhages  are  specially  frequent. 

Microscopically,  myeloid  sarcomata  are  usually  composed 
of  spindle-shaped  cells  with  large  multinucleated  masses  of 
protoplasm  scattered  more  or  less  regularly  through  them. 
These  giant  cells  are  sometimes  absent  over  considerable  areas. 
They  may  be  differentiated  from  the  giant  cells  of  tuberculosis 
by  their  nuclei  occurring  all  through  the  cell,  especially  in  the 
centre,  whereas  the  tubercle  giant  cell  has  its  nuclei  arranged 
in  a  zone  at  the  margin.  Haemorrhages  are  frequent. 

Glio-sarcoma  is  a  type  found  in  the  central  nervous 
system  and  retina.  It  is  the  malignant  analogue  of  the 
glioma  and  resembles  it  in  appearance  (see  p.  243). 


292  TUMOURS 

Sarcomata  sometimes  show  a  greater  amount  of  differentia- 
tion of  tissue.  Those  arising  in  connection  with  bone  may  show 
a  tendency  to  form  cartilage  (chondro  -  sarcoma)  or  bone 
(osteo-sarcoma)  or  a  mixture  of  the  two.  Such  tissue  only 
imperfectly  reproduces  the  structure  of  its  normal  homologue. 
The  cartilage  is  very  irregular  and  has  a  marked  tendency 
to  undergo  myxomatous  change.  The  bony  tissue  is  only 
imperfectly  formed,  the  calcareous  material  being  deposited  in 
rather  than  combined  with  the  intercellular  tissue.  Necrosis 
and  haemorrhage  are  prominent  features  of  such  tumours. 

Endothelioma. — Sites. — This  is  a  term  of  somewhat 
indefinite  significance  applied  to  tumours  occurring  in 
connection  with  serous  membranes  such  as  the  pleura, 
peritoneum  and  dura  mater,  but  also  in  other  parts  of  the 
body  in  relation  to  lymph  and  blood  channels  and  lymph 
glands.  Apparently  they  may  originate  in  any  position 
where  connective  tissue  tends  to  assume  a  flattened 
character  in  consequence  of  forming  a  lining  to  a  channel, 
space  or  cavity. 

Appearance.  —  Such  tumours  have  the  characters  and 
appearances  of  sarcomata  in  general. 

Microscopically,  the  chief  characteristic  is  a  tendency  for  the 
cells  to  group  themselves  so  as  to  form  rounded  or  irregularly 
shaped  spaces  into  which  the  flattened  or  polygonal  cells  pro- 
ject. Owing  to  the  above-mentioned  microscopic  appearances 
the  term  alveolar  sarcoma  is  often  applied  to  these  tumours. 

Perithelioma  is  a  term  applied  to  a  neoplasm  in  which 
there  is  whorl -like  arrangement  of  the  constituent  cells 
round  a  central  blood  or  lymph  space,  the  cells  being  of  a 
flattened  or  polygonal  shape.  Such  tumours  are  found, 
specially  in  the  central  nervous  system,  growing  from  the 
membranes  of  the  brain  or  cord.  Sometimes  in  the  centres 
of  these  whorls  of  cells  instead  of  a  space  there  may  be  a 
mass  of  calcareous  material.  Such  tumours  have  been 


MALIGNANT  TUMOURS  293 

called  Psammomata  or  "  brain  sand  tumours."    They  occur 
in  relation  to  the  cerebral  meninges  and  ventricles. 

Angiosarcoma. — Closely  related  to  the  above  are  malig- 
nant growths  in  which  spaces  containing  blood  are  the 
principal  feature.  The  spaces  are  lined  with  endothelial- 
like  cells.  Such  tumours  have  of  course  a  very  vascular 
appearance.  They  are  not  uncommon  in  the  brain,  and  are 
found  occasionally  in  the  spleen. 

Myelomata  are  tumours  which  arise  from  one  or  other 
of  the  blood-forming  elements  in  the  bone  marrow.  The 
cells  composing  them  are  rounded  or  polygonal  and  may 
resemble  the  myelocyte,  lymphocyte,  nucleated  red  cell  or 
plasma  cell.  They  occur  as  multiple  white  masses  in  the 
interior  of  bones  such  as  sternum,  ribs,  spinal  column,  skull, 
femur,  humerus.  They  destroy  and  distend  the  bone, 
leading  sometimes  to  spontaneous  fracture.  In  the  urine  a 
peculiar  form  of  albumose  (Bence- Jones  albumose)  is  some- 
times found  in  such  cases. 


Malignant  Melanotic  Tumours 

Melanin  pigment  occurs  normally  in  the  deeper  cells  of 
the  stratum  Malpighii.  Subjacent  to  these,  in  the  cutis  vera, 
are  certain  spindle-shaped  cells  which  may  contain  pigment 
and  which  are  known  as  chromatophore  cells.  Whether  these 
cells  elaborate  the  pigment  from  the  blood  or  bear  it  to  other 
destinations  from  the  epithelial  cells  is  uncertain.  Similar 
pigment  is  also  found  in  the  choroid  and  in  the  iris.  The 
chemical  characters  of  the  pigment  vary  somewhat  according 
to  the  site,  but  as  a  rule  it  contains  a  considerable  quantity 
of  sulphur  and  little  or  no  iron.  In  colour,  under  the  micro- 
scope, the  pigment  varies  from  yellow  to  dark  brown.  To 
the  naked  eye  it  usually  appears  black. 

The  exact  position  from  the  point  of  view  of  classification 


294  TUMOURS 

of  many  of  these  melanotic  tumours  is  uncertain.  Some 
have  the  microscopic  characters  of  sarcomata  of  the  spindle- 
cell  type.  In  others  the  cells  are  polygonal  and  others  again 
have  the  appearance  of  epitheliomata.  Pigment ed  meso- 
blastic  cells  are  found  in  the  choroid  and  iris,  and,  as  we  have 
seen,  cells  resembling  connective  tissue  corpuscles  (chroma- 
tophore  cells)  are  found  in  the  cutis,  but  whether  these  latter 
form  the  origin  of  melanotic  tumours  is  uncertain.  The 
pigment-containing  cells  in  the  pigment  ed  moles  are  also  of 
uncertain  nature.  Many  of  these  melanotic  tumours  probably 
arise  from  the  cells  in  the  deeper  layers  of  the  stratum 
Malpighii,  and  are  therefore  of  epithelial  origin  and  should 
be  classified  with  the  carcinomata. 

Sites. — Tumours  which  contain  melanin  are  met  with 
primarily  in  connection  with  the  skin  (particularly  in 
relation  to  pigmented  moles)  and  with  the  eye.  Secondary 
deposits  occur  specially  in  lymphatic  glands  and  in  the  liver. 
Such  tumours,  as  a  rule,  are  exceedingly  malignant  in  the 
sense  that  secondary  growths  may  occur  early  when  the 
primary  tumour  is  minute. 

Appearance. — The  appearance  of  such  tumours  is  very 
characteristic  owing  to  the  presence  of  the  melanin,  which 
imparts  a  dark-brown  to  black  colour  to  the  growth.  The 
pigment  may,  however,  be  present  only  in  parts,  the  pigment- 
free  areas  having  the  appearance  of  an  ordinary  sarcoma. 
The  student  should  be  careful  not  to  fall  into  the  error  of 
calling  a  neoplasm  in  the  lung,  where  carbon  pigment  is 
normally  present,  melanotic. 

Microscopically,  such  tumours,  as  already  stated,  vary 
considerably.  The  cells  may  be  spindle  shaped,  polygonal  or 
epithelioid.  The  pigment  is  present  within  the  cells  and  in 
masses  outside.  Considerable  areas  of  the  tumour  may  have 
no  pigment  present  at  all.  The  pigment  is  yellow  to  dark 
brown  in  colour  and  is  exceedingly  resistant  to  reagents  of  all 
kinds.  For  its  demonstration  sections  of  the  tumour  should 


MALIGNANT  TUMOURS  295 

be  stained  in  the  nuclear  dye  (e.g.  hasmatein)  only.     The  cells 
often  have  an  alveolar  arrangement. 


CARCINOMATA  OR  CANCERS 

These  are  malignant  tumours,  the  essential  constituent  of 
which  is  epithelium.  In  addition  to  the  epithelium  there  is 
always  a  greater  or  smaller  amount  of  connective  tissue  stroma, 
which  supports  the  epithelial  elements  and  in  which  run  the 
nutrient  vessels.  This  stroma  is  derived  in  part  from  the 
pre-existing  tissue  of  the  area  in  which  the  tumour  occurs ; 
to  a  much  greater  extent  it  is  a  new  development  from  the 
fibrous  tissue  of  the  host.  It  is  this  occurrence  of  two 
distinct  types  of  tissue — epithelial  elements  and  supporting 
connective  tissue  scaffolding — which  distinguishes  this  type 
of  malignant  growth  from  the  sarcomata.  In  the  case  of  the 
latter  the  cells  tend  to  be  all  of  one  type  and  are  diffusely 
arranged. 

Inasmuch  as  there  are  two  main  types  of  epithelium — 
(i)  the  stratified  squamous  type,  covering  skin  and  lining 
mouth  and  oesophagus ;  (2)  the  glandular  type,  covering  the 
intestine  and  forming  the  secreting  elements  of  glands — so 
there  are  two  main  types  of  carcinomata :  (i)  Squamous 
epitheliomata ;  (2)  Adeno-carcinomata. 

The  characters  of  these  tumours  are  those  of  malignant 
growths  in  general.  The  main  underlying  property  is  that 
of  invasion  of  the  normal  tissues.  Sometimes,  in  the  case 
of  a  tumour  of  a  surface  such  as  the  skin  or  of  a  lining 
membrane  of  a  viscus  such  as  the  bowel,  enlargement  may 
take  place  mainly  by  projection  of  the  growth.  Such  an 
appearance  often  receives  the  name  "  fungating  "  tumour 
(Fig.  69).  As  a  rule,  however,  the  tumour  grows  chiefly  by 
penetrating  the  healthy  tissues  around. 

When  growing  on  one  of  the  surfaces — skin  or  bowel — 
ulceration  of  the  growth  very  soon  occurs.  This  leads  to 


296  TUMOURS 

invasion  of  organisms  and  absorption  of  toxins,  an  important 
factor  in  the  production  of  the  cachexia  of  cancer. 

The  erosion  of  the  tissues  by  the  cancer  cell  elements 
leads  to  invasion  of  lymph-  and  blood-vessels.  It  is  chiefly  by 
the  former  that  carcinomata  spread,  so  that  the  secondary 
deposits  are  to  be  sought  for  first  of  all  in  the  nearest 
lymphatic  glands.  Spread  may  also  occur  by  way  of  the 
blood-stream,  secondary  foci  occurring  in  the  internal  organs 
such  as  liver  and  lungs. 

This  invasion  by  the  cancer  cells  is  resented  by  the  normal 
tissues,  with  the  result  that  an  inflammatory  reaction  of  a 
subacute  type  occurs  in  the  tissues  at  the  growing  margins  of 
such  growths.  This  inflammatory  reaction  manifests  itself 
by  an  infiltration  of  the  tissues  with  small  round  cells,  similar 
in  appearance  to  the  lymphocytes  of  the  blood  but  in  reality 
of  diverse  origin. 

The  metastases  resemble  as  a  rule  the  primary  growth  fairly 
closely.  They  show  the  same  division  into  epithelial  elements 
and  supporting  fibrous  tissue.  The  tendency  is,  however, 
for  the  epithelial  elements  to  show  less  marked  differentiation. 
Thus  in  squamous  epitheliomata  the  secondary  deposits 
may  show  little  or  no  tendency  to  cornification  and  formation 
of  cell  nests. 

The  cancer  cells  themselves  vary  greatly  in  shape  and 
appearance.  As  a  rule  they  tend  to  be  larger  than  their 
normal  homologues.  They  may  show  evidence  of  secretory 
activity  when  they  arise  from  glandular  epithelium.  This  is 
indicated  by  vacuolation  of  the  cells  and  by  the  accumulation 
of  mucinous  or  colloid  material  in  the  gland  spaces.  They 
do  not  preserve  the  normal  relationship  with  their  surroundings. 
Thus  the  groups  of  gland  cells  have  no  basement  membrane. 
Instead  of  the  normal  single  layer  of  cells  forming  an  acinus 
there  are  often  several  layers. 

Mitotic  figures  are  often  numerous,  their  number  being 
taken  as  a  measure  of  the  rapidity  of  the  growth  of  the  tumour. 


MALIGNANT  TUMOURS  297 

The  figures  are  frequently  abnormal ,  showing  multipolar 
division.  The  chromosomes  are  more  often  he tero typical 
(i.e.  rounded  instead  of  V-shaped — a  condition  characteristic 
of  the  stage  of  maturation  of  the  sexual  cells)  than  is  the 
case  in  the  cell  dividing  normally. 

Various  forms  of  inclusions  are  commonly  met  with  in 
the  cancer  cells.  These  are  known  as  "  cancer  bodies,"  and 
have  from  time  to  time  been  taken  as  representing  parasites 
of  various  types.  They  are  produced  by  the  phagocytic 
activity  of  the  cells  taking  up  leucocytes,  other  cancer  cells , 
red  blood  corpuscles,  etc.  They  appear  as  rounded  bodies, 
usually  with  a  distinct  space  surrounding  them.  Other 
bodies  occurring  mainly  between  the  cells,  usually  in  groups, 
are  found.  They  are  known  as  Russell's  fuchsin  bodies,  and 
probably  represent  hyaline  degenerations  of  cells  or  segrega- 
tions of  albuminous  material. 

Carcinomata  occur  (i)  at  or  near  the  orifices  of  the  body — 
lip,  tongue,  rectum,  vagina;  (2)  at  points  where  normally 
there  is  narrowing  of  a  canal — pylorus,  ileo-caecal  valve ; 
(3)  at  points  where  a  canal  changes  its  direction — hepatic, 
splenic,  simoid  flexures  of  large  intestine ;  (4)  in  glands  such 
as  the  mammary,  and  in  organs  such  as  the  uterus,  which 
are  periodically  undergoing  hypertrophy  and  involution.  In 
other  words,  there  is  a  marked  association  of  cancer  with 
chronic  irritation  of  various  kinds. 

The  tumours  commonly  grow  from  a  single  centre.  The 
various  prolongations  of  the  growth  will  be  found  all  to 
radiate  from  a  single  point. 

As  previously  indicated,  carcinomata  may  be  divided 
into  two  main  groups — (i)  Squamous  epitheliomata ;  (2) 
Adeno-carcinomata  or  glandular  cancers. 

I.  Squamous   Epitheliomata 

Sites. — These  grow  from  (a)  the  skin  ;  (b)  mucous  membranes 
covered  with  stratified  squamous  epithelium ,  such  as  mouth) 


298  TUMOURS 

(esophagus,  vagina,  cervix  uteri  ;  (c)  embryonic  epithelial  canals, 
such  as  the  thyro-glossal  duct.  Occasionally  they  occur  where 
no  squamous  epithelium  is  found  normally,  e.g.  in  stomach 
and  gall-bladder. 

Appearances. — Such  tumours  occasionally  project  beyond 
the  general  surface,  forming  a  fungating  mass.  More  com- 
monly they  appear  as  ulcerated  areas,  the  margins  of  the  ulcer 
being  raised  and  hard  (Fig.  57).  On  cutting  down  through  the 
floor  of  the  ulcer  so  that  the  relationship  with  the  subjacent 
tissues  is  displayed,  the  opaque  white  epithelium  will  be  found 
penetrating  the  tissue  for  a  variable  distance. 

Microscopically,  such  tumours  are  found  to  be  formed  of 
tongue-like  prolongations  of  epithelium.  Sometimes  these  can 
be  traced  in  continuity  with  the  original  mass,  at  other  times 
they  are  cut  transversely  and  appear  as  isolated  rounded 
masses.  At  the  spreading  margin  and  in  the  early  stage  of 
the  condition  these  columns  of  epithelial  cells,  being  only  a 
few  cells  thick,  show  no  differentiation  into  layers.  In  the 
larger  masses  the  central  cells  become  flattened  and  undergo 
a  change  similar  to  the  keratinisation  of  the  stratum  corneum. 
When  the  columns  are  cut  transversely  the  appearance  is  that 
of  a  central  whorl  of  flattened  cells  concentrically  arranged, 
representing  the  stratum  corneum  and  surrounded  by  the  poly- 
gonal epithelial  cells  representing  the  cells  of  the  stratum 
Malpighii,  and  like  them  showing  intercellular  bridges.  This 
appearance  is  known  as  a  "cell  nest."  These  cell  nests  must 
be  distinguished  from  hair  follicles  and  other  normal  structures. 

The  cells  forming  these  epithelial  down-growths  resemble 
the  normal  cells  found  in  the  deeper  layers  of  the  stratum 
Malpighii.  They  tend,  however,  to  be  somewhat  larger  than 
their  normal  homologue.  Mitotic  figures  are  usually  to  be 
found  amongst  their  nuclei,  sometimes  in  large  numbers. 

Between  these  columns  of  epithelial  cells  are  the  tissues 
— muscle,  connective  tissue,  glandular  structures — which  have 
been  invaded  by  the  growth.  These  are  infiltrated  by  small 
round  cells.  These  cells  are  specially  well  seen  at  the  growing 
margin  of  the  tumour,  the  appearance  being  known  as  small 
round -cell  infiltration.  Such  small  round  cells  may  be 


MALIGNANT  TUMOURS  299 

lymphocytes  from  the  blood  or  young  connective  tissue  cells. 
Haemorrhages  are  not  uncommonly  met  with  in  the  marginal 
portions  of  the  growth.  In  addition  to  the  pre-existing  tissues 
of  the  part  there  are  strands  of  newly-formed  connective  tissue 
between  the  masses  of  epithelium.  These  constitute  the 
scaffolding  of  the  new  growth,  and  are  composed  of  granula- 
tion tissue,  with  a  large  proportion  of  small  round  cells. 

Rodent  Ulcer. — This  is  a  variety  of  squamous  epithelioma 
with  a  low  degree  of  malignancy. 

Site. — The  condition  occurs  in  old  people  on  any  part  of 
the  skin,  but  most  frequently  on  the  upper  part  of  the  face, 
about  the  root  of  the  nose,  the  external  angle  of  orbit,  the 
side  of  the  cheek  and  the  forehead. 

Appearance. — It  appears  as  an  ulcerated  area  with  raised 
margins,  which  erodes  down  to  the  bone  and  may  destroy 
the  nose  or  ear,  but  which  does  not  produce  metastases  and 
is  very  amenable  to  treatment.  The  tumour  is  believed  to 
originate  from  the  hair  follicles  or  sweat  glands,  rather  than 
from  the  epithelium  proper. 

Microscopically,  the  condition  is  characterised  by  the 
presence  of  masses  of  epithelial  cells  penetrating  the  subjacent 
tissues.  There  are  certain  points  of  distinction  between  this 
and  the  ordinary  squamous  epithelioma.  (i)  The  cells  are 
cylindrical  or  spindle  shaped,  and  are  as  a  rule  smaller  than 
those  found  in  the  epithelioma.  (2)  There  are  no  cell  nests  or 
only  imperfect  attempts  at  keratinisation  in  the  centres  of  the 
epithelial  masses.  (3)  There  is  little  or  no  evidence  of  cell 
reaction  (round-cell  infiltration)  in  the  tissues  which  are  being 
invaded.  (4)  The  line  between  epithelial  masses  and  fibrous 
stroma  is  sharply  marked. 

II.  Adeno-Carcinomata,  Malignant  Adenomata,  or 
Glandular  Cancers 

These  tumours  are  composed  of  gland  cells  arranged  in 
alveoli  or  in  solid  masses  and  of  intervening  supporting  fibrous 


300  TUMOURS 

tissue.  This  stroma  is  often  absent  at  the  spreading  margin 
of  the  growth,  the  gland  cells  occurring  in  and  between  the 
tissue  elements  of  the  part. 

As  stated  above,  the  epithelial  elements  show  two  fairly 
well-marked  types  of  arrangement.  They  may  occur  in 
acini,  i.e.  with  an  arrangement  of  the  cells  similar  to  what  is 
found  in  most  normal  glands,  the  epithelial  elements  lining 
a  space;  or,  on  the  other  hand,  they  may  occur  in  solid 
masses.  In  the  first  type  the  cells  tend  to  be  columnar ;  in 
the  second  type  from  mutual  pressure  they  assume  a  rounded 
or  spheroidal  form.  This  difference  in  the  shape  of  the 
cancer  cells  is  usually  taken  as  a  basis  for  further  division 
into  two  types,  viz. :  (i)  Columnar  cell  carcinoma,  and 
(2)  Spheroidal  cell  carcinoma.  By  some  authorities  the 
term  adeno- carcinoma  is  reserved  exclusively  for  the  first 
type. 

There  are  other  types  of  carcinomata  occurring  in  certain 
glandular  organs,  the  cells  of  which  are  arranged  not  in  acini 
but  in  columns.  This  arrangement  obtains  in  the  liver,  and 
in  glandular  cancer  of  the  liver  the  columnar  structure  may 
be  reproduced. 

Occasionally  a  tumour  may  show  an  acinous  arrangement 
in  one  part  and  in  another  the  cells  may  be  massed  together. 
At  the  same  time  the  tumours  of  the  two  types  preserve  their 
characters  with  a  fair  degree  of  constancy. 

1.  Columnar  Cell  Carcinoma. — Sites. — These  tumours 
are  found  most  frequently  in  the  stomach  and  the  intestinal 
tract.  They  are  also  found  in  the  liver,  pancreas,  uterus, 
mammary  gland,  etc. 

Appearance. — They  may  occur  as  projecting  fungating 
masses  (Fig.  69),  or  merely  as  ulcerated  surfaces  with 
infiltration  and  thickening  of  the  walls  of  the  gut.  There  is 
commonly  annular  contraction  of  the  gut  at  the  affected 
point.  Secondary  deposits  are  common  in  the  nearest 


MALIGNANT  TUMOURS  301 

lymph  glands  and  in  the  liver.    Such  secondary  growths 
have  a  very  variable  appearance. 

Microscopically,  these  tumours  are  mainly  characterised  by 
a  downward  growth  of  the  gland  elements  into  the  wall  of  the 
viscus,  so  that  gland  acini  are  present  in  the  submucous  and 
muscular  layers.  At  the  same  time  the  cancerous  epithelium 
differs  from  the  normal.  The  cells  tend  to  be  larger ;  they 
vary  somewhat  in  size  and  shape.  They  possess  no  basement 
membrane.  Mitotic  figures  may  be  found  in  considerable 
numbers.  There  is  a  tendency  to  form  several  layers  of 
epithelium  instead  of  one,  and  sometimes  there  is  no  lumen 
present  owing  to  the  multiplication  of  the  gland  cells.  There 
is  an  inflammatory  infiltration  of  the  normal  tissues  at  the 
spreading  margin  of  the  growth.  Where  the  tumour  is  pro- 
jecting into  the  lumen  of  the  gut,  also  when  it  occurs  as  large 
solid  masses  in  organs  such  as  the  liver,  also  in  the  secondary 
deposits  in  glands,  a  stroma  of  connective  tissue  forms  which 
carries  the  nutrient  blood-vessels. 

2.  Spheroidal  Cell  Carcinomata. — These  tumours  are 
commoner  in  certain  situations,  e.g.  breast,  but  they  may 
occur  anywhere.  It  has  been  customary  for  long  to  distin- 
guish them  according  to  their  physical  characters  into 
Scirrhous  or  hard  cancers,  and  Encephaloid  or  soft  cancers. 
Such  names  are  still  in  use,  and  although  the  distinction 
depends  merely  upon  the  relative  preponderance  of  fibrous 
tissue  and  cancer  cells,  it  is  convenient  to  describe  them 
under  these  headings. 

(a)  Scirrhous  Cancer. — Sites.— This  is  found  most  typically 
in  the  breast,  although  it  also  occurs  in  stomach,  intestine, 
pleura,  ovary. 

Appearance. — Such  tumours  are  opaque  white,  tendinous- 
looking  masses  radiating  into  the  surrounding  parts  (Fig.  103). 
They  are  very  hard,  and  creak  on  being  cut.  Opaque  yellow 
areas  of  necrotic  change  are  sometimes  visible,  although 
these  are  not  nearly  so  numerous  as  in  the  encephaloid  type. 
In  the  case  of  the  breast  there  is  very  commonly  indrawing 


302  TUMOURS 

of  the  nipple.    The  cut  surface  often  becomes  depressed  and 
cup  shaped. 

Microscopically ',  the  tumour  shows  a  large  preponderance 
of  the  fibrous  stroma  element.  This  connective  tissue  in  the 
more  central  parts  is  well  developed  and  shows  few  cells.  At 
the  growing  margin  it  is  more  cellular.  In  this  fibrous  stroma 
are  elliptical  spaces  filled  with  cancer  cells.  The  cancer  cells 
themselves  are  spheroidal  from  mutual  pressure,  and  there  is 
often  a  space  (artificially  produced  by  shrinkage)  between  them 
and  the  fibrous  stroma.  Mitotic  figures  may  be  found.  No 
basement  membrane  is  present.  In  the  centre  of  the  growth 
the  groups  of  cancer  cells  may  be  few  and  far  between.  At 
the  growing  margin  they  are  more  numerous.  Occasionally 
there  may  be  attempts  at  the  formation  of  a  lumen. 

(b)  Encephaloid,  Medullary  or  Soft  Cancer. — Sites.— They 
occur  in  sites  such  as  the  breast,  stomach  and  pancreas. 

Appearance. — The  tumours  in  this  type  tend  to  be  larger, 
softer,  more  vascular,  and  there  are  more  often  areas  of 
necrosis. 

Microscopically,  they  are  characterised  by  a  smaller  pro- 
portion of  fibrous  stroma  and  a  larger  proportion  of  glandular 
epithelium.  The  cancer  cells  vary  in  size,  but  they  occur 
in  much  larger  masses  than  in  the  scirrhous  type.  Further, 
necrotic  changes  are  very  commonly  present  amongst  them. 

3.  Colloid  Cancer  is  a  special  type  of  Adeno-carcinoma, 
characterised  by  the  accumulation  of  mucinous  material  in 
the  spaces,  which  becomes  inspissated  and  hence  gum-like  in 
consistence. 

Sites. — The  stomach,  large  intestine  and  mammary  gland 
are  the  common  sites  for  such  growths. 

Appearance. — It  appears  as  gelatinous  translucent  material, 
in  greater  or  less  amount,  in  the  tumour  and  its  secondary 
deposits.  Otherwise  the  growth  has  the  appearance  of  a 
columnar  cell  carcinoma. 


TERATOMATA  303 

Microscopically,  these  tumours  often  show  in  parts  the 
characters  of  the  ordinary  columnar  cell  carcinoma.  In  other 
parts,  the  gland  acini  are  dilated  and  the  lumen  filled  with 
homogeneous  or  slightly  fibrillated  material.  The  cells  are 
often  vacuolated  from  the  presence  of  secretion.  They 
become  detached  from  the  fibrous  stroma  and  eventually 
disappear  altogether,  fusing  with  the  mucinous  contents  of  the 
spaces. 

0.  TERATOMATA 

There  remains  for  consideration  a  number  of  tumour 
formations  traceable  to  some  defect  in  the  development  of 
the  individual,  also  others  due  to  the  grafting  of  the  embryo's 
tissues  upon  the  maternal  organism. 

To  the  first  group  belongs  the  Teratoma  properly  so 
called  or  Dermoid  Cyst. 

Such  tumours  are,  as  their  name  indicates,  usually  found 
in  the  form  of  cysts.  The  cyst  wall  is  developed  from  the 
tissues  of  the  host.  The  wall  is  lined  by  skin  epithelium  and 
encloses  chiefly  soapy-looking  material  and  hairs,  frequently 
also  teeth,  skin,  bone,  cartilage,  muscle,  nerve  elements  it 
may  be,  and  rudimentary  viscera.  The  causation  of  the 
condition  is,  in  most  cases,  the  inclusion  of  the  elements  of 
one  individual  within  the  body  of  another.  The  growth  is 
simple  in  nature. 

Site. — The  site  of  such  tumours  is  commonly  in  or  near  the 
ovary  (Fig.  102),  but  they  may  also  occur  in  the  testicle,  the 
neighbourhood  of  the  sacrum,  the  side  of  the  neck  and  face ; 
also  very  occasionally  in  the  brain. 

Appearance. — The  tumour  varies  much  in  size.  Occasionally 
it  may  be  as  large  as  a  foetal  head.  As  a  rule  there  is  a  point, 
the  so-called  "  protuberance/'  which  represents  the  head  and 
from  which  arises  a  tuft  of  long  hairs. 

Microscopically,  dermoid  cysts  show  a  great  variety  of  types 
of  tissue — stratified  squamous  epithelium,  sweat  glands,  hair 


304  TUMOURS 

follicles,  cartilage,  bone,  gland  acini   lined  by  epithelium  of 
various  kinds,  etc. 

To  the  second  group  (those  due  to  the  grafting  of  embryo 
tissues  upon  the  maternal  organism)  belong  (a)  the  placental 
mole,  or  myxoma  of  the  chorion,  already  described  on  p.  268  ; 
and  (b)  the  chorion-epitlielioma  or  deciduoma  malignum. 

Chorion-Epithelioma 

This  is  an  exceedingly  malignant  condition  which  may 
follow  an  abortion  or  full-time  pregnancy,  also  its  simple 
analogue  the  placental  mole. 

The  outer  surface  of  the  chorionic  villi  consists  of  the  layers 
of  foetal  epiderm.  The  most  external  (syncytium)  is  formed  of 
multinucleated  masses  of  protoplasm  (giant  cells).  These 
possess  normally  intense  phagocytic  properties,  whereby  the 
villi  are  enabled  to  penetrate  the  maternal  tissue  and  come  to 
lie  within  the  blood  sinuses  of  the  uterus.  Underneath  this  layer 
is  a  second,  in  which  the  cells  are  separate  and  do  not  stain  so 
deeply.  This  is  what  is  known  as  the  Langhans  layer. 

After  an  abortion  or  full-time  pregnancy  the  layers  of  cells 
covering  the  chorionic  villi  may  take  on  abnormal  growth ; 
developing  into  a  tumour  which  is  essentially  cellular  (having 
no  intercellular  material),  which  shows  no  arrangement  of  its 
elements  and  possesses  no  blood-vessels. 

Sites. — The  usual  site  for  such  tumours  is  the  uterus, 
following  abortion  or  full-time  pregnancy.  Occasionally 
they  occur  independently  of  pregnancy,  as  for  example 
in  the  testicle.  Such  are  probably  due  to  germ  cells  taking 
on  active  development  and  producing  a  trophoblast  (the  two 
layers  of  cells  covering  the  villi  are  known  as  trophoblast) 
from  which  the  tumour  arises. 

Appearance. — Such  a  tumour  appears  as  a  soft  spongy 
vascular  mass  in  the  wall  of  the  uterus.  Necrosis  and  haemor- 
rhage are  characteristic  features  of  it,  Metastatic  growths 


TERATOMATA  305 

develop  very  early  and  are  found  especially  in  the  lungs,  but 
also  in  the  liver  and  kidneys. 

Microscopically,  two  types  of  cells  are  found  in  the  parts  of 
the  tumour  which  are  not  necrosed :  (i)  large  plasmodial 
masses,  mostly  multinucleated,  derived  from  the  synctium,  the 
nuclei  of  which  are  in  rapid  division  and  show  all  varieties  of 
abnormal  mitoses  ;  (2)  groups  of  smaller,  polyhedral  cells 
derived  from  the  Langhans  layer.  Both  types  of  cell  are 
found  in  the  uterine  wall  penetrating  the  tissues  and  eroding 
blood-vessels. 


TABLE  OF  TUMOURS 

A.  SIMPLE  TUMOURS — 

Fibroma,  Myxoma,  Lipoma,  Chondroma,  Osteoma,  Myoma, 
Angioma,  Lymphoma,  Glioma,  Papilloma,  Adenoma. 

B.  MALIGNANT  TUMOURS — 

(a)  Sarcomata — 

Small  round-celled,  Lymphosarcoma,  Large  round-celled,  Small 
spindle-celled,  Large  spindle-celled,  Mixed  celled,  Myeloid, 
Chondro-sarcoma,  Osteo-sarcoma,  Endothelioma,  Alveolar, 
Peritheiioma,  Angiosarcoma,  Myeloma,  Melanotic. 

(b)  Carcinomata — 

I.   Squamous  Epitheliomata. 

Rodent  ulcer. 
II.  Adeno-Carcinomata. 

1.  Columnar  Cell  Carcinoma. 

2.  Spheroidal  Cell  Carcinomata. 
Scirrhous,  Encephaloid. 

3.  Colloid  Cancer. 

C.  TERATOMATA — 

I.   Dermoid  Cyst. 
II.   Embryomata. 

Myxoma  of  Chorion  (simple). 
Chorion-Epithelioma  (malignant). 


CHAPTER   XV 

POINTS   TO   BE   REMEMBERED   IN   PERFORMING   AUTOPSIES 
ON   CASES   WITH   A   MEDICO-LEGAL   ASPECT 

GENERAL   METHOD   OF   PROCEDURE   IN 
MEDICO-LEGAL   CASES 

IT  must  be  remembered  that  all  cases  of  death  which  have  occurred 
suddenly  or  unexpectedly,  and  cases  of  death  where  no  medical 
man  has  been  in  attendance,  as  well  as  all  cases  of  death  from 
violence  whether  the  result  of  accident,  suicide  or  homicide,  are 
the  subject  of  inquiry  by  the  authorities — in  Scotland  the  Pro- 
curator-fiscal and  in  England  the  Coroner — and  that  in  all 
cases  of  the  above  nature  a  post-mortem  should  not  be  made 
without  instruction  from  the  authorities. 

It  must  also  be  noted  that  in  cases  of  accidental  injury  to 
work-people,  in  which  death  ensues  either  at  the  time,  or,  it 
may  be,  months  afterwards,  a  public  inquiry  may  be  held  by 
the  authorities,  and  that  therefore  a  post-mortem  should  not 
be  made  until  the  authorities  have  been  communicated  with. 

In  performing  a  medico-legal  post-mortem,  the  following 
precautions  should  be  exercised. 

1.  The  body  should,  if  possible,  be  identified  by  relations 
or  the  police  in  the  presence  of  the  doctor  before  the  post-mortem 
is  commenced. 

2.  Under  all  circumstances,  such  a  post-mortem  must  be 
complete,  i.e.  every  cavity  and  organ  must  be  examined. 

306 


MEDICO-LEGAL  POST-MORTEMS  307 

Note. — Unless  there  are  special  circumstances  indicating 
its  necessity,  it  is  not  usual  to  examine  the  spinal  cord. 

3.  If  there  is  any  suspicion  of  poisoning,  the  following 
tissues  should  be  preserved  : — 

(1)  Stomach  and  its  contents. 

(2)  Intestines  and  their  contents. 

(3)  Liver  (at  least  half). 

(4)  Kidney  and  spleen. 

(5)  Some  blood. 

(6)  Urine. 

In  special  cases  it  may  be  advisable  to  remove  other  organs, 
such  as  the  brain,  lungs,  etc. 

4.  All  tissues,  etc.,  removed  must  be  placed  in  glass  vessels 
which  are  chemically  clean,  which  should  then  be  made  air- 
tight, sealed  and  labelled.    The  label  should  bear  on  it  the 
nature  of  its  contents,  and  the  date  of  the  post-mortem,  and 
should  be  signed  by  the  doctor. 

Each  tissue  or  organ  should  be  preserved  in  a  sepa- 
rate vessel,  and  no  preservative  of  any  sort  should  be 
used. 

In  Scotland  the  medical  examiner  must  write  a  report  of 
the  examination  in  " soul  and  conscience"  form. 

This  medical  report  must  contain  the  following  : — 

(1)  Date  and  place. 

(2)  State  by  whom  body  has  been  identified. 

(3)  Where  the  examination  was  performed. 

(4)  An  account  of  the  external  appearances. 

(5)  An  account  of  the  internal  appearances. 

(6)  Conclusion  from  above  as  to  the  cause  of  death. 

It  is  essential  that  any  alterations  should  be  initialled, 
but  it  is  better  to  rewrite  the  report  if  additions  or  alterations 
have  to  be  made. 

No  opinions  other  than  the  conclusion  as  to  the  cause  of 
death  should  be  given  in  the  report. 

No   technical  terms  should  be  employed  in   writing  the 


308  MEDICO-LEGAL  POST-MORTEMS 

report.  The  language  used  should  be,  as  far  as  possible, 
popular. 

The  report  should  be  signed  by  the  medical  man  or  men, 
their  medical  qualifications  being  appended. 

The  report  is  sent  to  the  Procurator  -  Fiscal  of  the 
district. 

In  England  a  written  report  is  not  as  a  rule  sent  to  the 
Coroner.  The  doctor  gives  his  evidence  usually  at  the 
Coroner's  inquest,  and  should  have  his  notes  of  the  post- 
mortem  examination  with  him.  His  evidence  at  the  inquest 
is  given  on  oath,  and  it  should  be  remembered  that  all  state- 
ments made  there  are  written  down,  forming  his  "  deposition/' 
and  that  this  deposition  is  produced  in  any  subsequent 
proceedings. 

POST-MORTEMS  ON  NEWLY-BORN  INFANTS 

In  performing  sectios  upon  newly -born  children  the 
questions  which  require  answering  are  : — 

1.  Was  the  child  viable  ?  i.e.  was  development  sufficiently 
far  advanced  for  the  child  to  be  able  to  live  apart  from  the 
mother  ? 

2.  Did  the  child  actually  live  (i.e.  breathe)  either  during 
or  after  birth  ? 

3.  If  the  child  lived,  what  was  the  cause  of  its  death  ? 
In  order  to  be  able  to  answer  these  questions  the  points  of 

chief  importance  to  note  are  : — 

External  Examination. — Note  the  length  of  body,  weight, 
the  condition  of  the  finger-nails,  the  presence  of  the  testicles 
in  the  scrotum ;  the  presence  or  absence  of  a  caput  succeda- 
neum  (the  presence  of  such  indicating  that  the  blood  was 
circulating  during  birth)  and  head  moulding. 

The  condition  of  the  umbilical  cord,  whether  cut  or  torn, 
and  whether  any  evidence  of  a  line  of  separation  having 
formed. 


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The  presence  of  vernix  caseosa,  blood  and  injuries  to  the 
skin. 

The  neck  should  especially  be  observed  for  abrasions. 

The  mouth  and  nostrils  should  be  inspected  for  the  presence 
of  froth  or  any  obstructing  body. 

Internal  Examination. — Attention  should  be  first  con- 
centrated upon  the  air-passages  and  lungs  in  order  to  deter- 
mine the  question,  Has  the  child  breathed  ? 

The  trachea  should  be  opened  and  carefully  examined  for 
the  presence  of  froth.  Some  authorities  recommend  the 
tying  of  the  trachea  before  opening  the  thorax.  This  is  not 
necessary. 

After  opening  the  thorax,  the  contents  of  the  thoracic 
cavity — lungs,  heart  and  thymus  gland — are  removed  and 
placed  entire  in  a  pail  of  water.  If  the  whole  mass  floats, 
there  can  be  no  further  doubt  about  the  question  of  the  child 
having  breathed.  Should  the  organs  sink,  then  the  individual 
lungs  should  be  carefully  examined  as  to  the  presence  of  any 
mottled  areas  that  would  indicate  partial  aeration.  The 
organs  should  then  be  cut  up  and  the  separate  portions  tested 
as  to  their  capacity  to  float.  It  may  be  advisable  in  some 
cases  to  examine  portions  of  the  organs  microscopically. 
(For  the  appearance  of  the  non-aerated  lung,  see  Atelectasis, 
p.  120.) 

Thereafter  the  examination  proceeds  in  the  usual  manner, 
attention  being,  however,  specially  directed  to  the  presence  of 
air  in  the  stomach  and  small  intestine  as  conclusive  evidence 
of  breathing ;  also  to  the  presence  of  food  in  the  stomach  as 
evidence  of  the  child  having  survived  its  birth  for  some 
time. 

In  all  cases  the  presence  or  absence  of  an  ossific  node  at  the 
lower  end  of  the  femur  must  be  determined  in  connection  with 
the  conclusion  as  to  the  stage  of  maturity  attained  (see  table, 
p.  309).  For  this  purpose  the  cartilage  of  the  epiphysis 
should  be  cut  away  in  thin  layers.  This  should  be  done  until 


MEDICO-LEGAL  POST-MORTEMS  311 

the  diaphysis  is  reached  in  order  to  be  quite  certain  as  to  the 
presence  or  absence  of  such  a  node.  Another  important 
centre  of  ossification  for  purposes  of  determining  the  stage 
of  maturity  reached  by  the  child  is  that  of  the  cuboid  (see 
table,  p.  309). 

The  common  causes  of  death  in  the  new-born  child  are 
as  follows  : — 

1.  Compression  of  the  umbilical  cord. 

2.  Protracted  delivery. 

3.  Malnutrition  and  immaturity. 

4.  Haemorrhage  from  the  cord. 

5.  Fracture,  usually  of  bones  of  skull. 

6.  Accidental  asphyxia. 

7.  Congenital  malformation  or  disease. 

Among  the  modes  by  which  death  may  be  caused  in  cases 
of  infanticide  are  the  following  : — 

1.  Suffocation. 

2.  Strangulation. 

3.  Drowning. 

4.  Fracture  of  skull. 

5.  Exposure  and  neglect. 

6.  Haemorrhage  from  the  cord. 


POST-MORTEM   CHANGES   PRODUCED 
BY   POISONS 

As  stated  elsewhere  (p.  21),  in  cases  of  poisoning  or  sus- 
pected poisoning,  after  examination  of  the  lips  and  mouth, 
the  tongue,  together  with  the  fauces,  oesophagus,  stomach, 
and  duodenum,  should  be  removed  and  examined  in  con- 
tinuity. 

It  should  be  carefully  borne  in  mind  that  with  certain  ex- 
ceptions the  appearances  in  cases  of  poisoning  are  by  no  means 
characteristic.  There  may  be  nothing  at  all  in  the  alimentary 
tract  to  suggest  poisoning.  Hence  the  necessity  in  all  suspicious 


312  MEDICO-LEGAL  POST-MORTEMS 

cases  for  the  preservation  of  the  organs  and  stomach  contents  for 
subsequent  chemical  analysis. 

Appearances  in  Poisoning  with  Corrosives. — In  all  such 
cases  there  is  softening  of  the  tissues  of  the  upper  alimentary 
tract — lips,  mouth,  oesophagus  and  stomach.  Sometimes 
there  is  necrosis  of  the  superficial  layers  of  viscera.  The  stomach 
shows  swelling  and  contraction  of  its  walls,  extravasation  of 
blood,  which  under  the  influence  of  the  acid  becomes  black) 
ulceration,  and  sometimes  perforation.  The  lining  shows  in 
some  cases  a  characteristic  colouring,  e.g.  in  the  case  of  nitric 
acid  a  yellow  colour.  The  appearances  in  sulphuric  and  hydro- 
chloric acid  poisoning  are  very  similar  and  cannot  in  many 
cases  be  differentiated.  The  only  point  of  distinction  is  that 
sulphuric  is  a  stronger  acid  than  hydrochloric,  hence  the 
corrosion  is  more  intense  and  there  is  a  greater  tendency  to 
perforation  ;  the  appearances  varying,  however,  according  to 
the  dilution  of  the  poison.  The  mucous  membrane  may  be 
charred  to  a  dark  brown  or  black  colour,  or  the  appearances 
may  be  merely  those  of  an  intense  gastritis.  In  poisoning 
with  carbolic,  if  the  acid  has  been  taken  in  a  concentrated 
form,  there  is  necrosis  of  the  mucous  membrane  particularly  of 
the  stomach  with  the  formation  of  a  putty-like  layer.  If  the 
acid  has  been  dilute,  the  interior  of  the  stomach  is  dusky 
red  from  hyperaemia. 

In  the  case  of  oxalic  acid  there  are  as  a  rule  no  external 
appearances.  When  the  acid  has  been  taken  in  the  concen- 
trated form  there  is  a  whitish  appearance  of  the  mucous  membrane 
inside  the  mouth.  When  dilute,  the  appearances  are  those 
of  irritation,  viz.  congestion. 

In  poisoning  with  caustic  alkalies  the  appearances  are 
somewhat  similar  to  those  found  in  the  case  of  acids,  but  the 
tissues  have  a  characteristic  soapy  feel.  In  ammonia  poisoning, 
in  addition  to  the  appearances  of  corrosion  in  the  alimentary 
tract,  there  is  generally  acute  inflammation  in  the  air-passages. 


MEDICO-LEGAL  POST-MORTEMS  313 

Appearances  in  Irritant  Poisoning. — The  common  irritant 
poisons,  such  as  arsenic,  antimony,  mercury,  produce  changes 
which  do  not  differ  to  any  extent  from  one  another.  By  the 
mere  naked-eye  examination  of  the  parts,  beyond  the  fact  that 
the  appearances  may  be  those  of  acute  gastritis  and  enteritis, 
there  is  little  that  is  characteristic.  In  some  instances,  even  when 
the  poison  has  been  taken  in  a  concentrated  form,  there 
may  be  little  to  suggest  that  the  case  is  one  of  poisoning. 
As  a  rule,  however,  the  mucous  membrane  of  the  alimentary 
canal  in  its  upper  part  is  swollen  and  in  parts  hyper&mic.  In 
other  words,  the  appearances  are  those  of  gastro-enteritis. 
Occasionally  there  is  ulceration. 

In  the  case  of  phosphorus  poisoning,  in  addition  to  the 
evidence  of  irritation  in  the  alimentary  tract,  there  is  extreme 
fatty  change  in  the  liver  (which  is  of  a  bright  yellow  colour), 
also  in  the  kidney  and  heart.  Such  cases  have  to  be  distin- 
guished from  acute  yellow  atrophy  of  the  liver  (see  p.  183), 
severe  anaemias,  and  toxaemias.  The  distinction  can,  of 
course,  be  readily  made  on  carrying  out  a  chemical  analysis 
of  the  organs. 

Appearances  in  Poisoning  with  Gases. — In  poisoning  with 
carbon  dioxide  the  appearances  are  merely  those  of  suffocation. 
The  face,  lips,  and  ears  have  a  dark  purple  colour. 

The  appearances  in  carbon  monoxide  (carbonic  oxide) 
poisoning  are  as  a  rule  typical.  Externally,  the  post-mortem 
lividity  is  of  a  pink  or  light  red  colour,  and  the  same  colour 
can  often  be  seen  in  the  lips,  conjunctive,  and  nails. 
Internally,  while  the  blood  in  bulk  may  show  no  change  yet 
wherever  it  is  in  a  thin  layer,  e.g.  the  mesentery,  etc.,  the 
pink  or  light  red  colour  is  most  striking.  The  liver,  spleen, 
kidneys  and  other  organs  frequently  show  the  same  change 
of  colour. 

A  simple  but  effective  test  can  be  carried  out  as  follows  : — 
Take  two  test-tubes  partly  filled  with  tap  water  ;  add  to  one 


314  MEDICO-LEGAL  POST-MORTEMS 

a  few  drops  of  normal  blood  and  to  the  other  a  few  drops  of 
blood  from  the  body  which  is  being  examined.  Normal  blood 
when  diluted  in  this  way  will  always  give  a  yellow  colour. 
Blood  containing  carbonic  oxide,  on  the  other  hand,  however 
much  it  is  diluted,  will  always  be  pink. 

A  conclusive  diagnosis  can  be  made  chemically  as  follows  : — 
A  small  quantity  of  normal  blood  is  placed  in  a  test-tube  and 
diluted  with  three  or  four  times  the  amount  of  tap  water.  A 
small  quantity  of  blood  from  the  case  under  investigation  is 
similarly  treated.  A  small  amount  of  tannic  acid  is  dissolved 
in  three  times  its  bulk  of  water.  Add  some  of  this  solution  to 
both  test-tubes  and  shake.  In  the  case  of  the  normal  blood  a 
chocolate  brown  precipitate  will  form.  Should  the  blood  from 
the  case  contain  carbon  monoxide  the  precipitate  will  be  a 
rose  red. 

In  poisoning  with  ammonia  gas  there  is  intense  inflamma- 
tion in  the  respiratory  passages. 

In  poisoning  with  alkaloids,  such  as  morphine,  strychnine, 
etc.,  there  is  usually  absolutely  no  abnormality  visible. 
Occasionally  tablets  of  the  poison  are  found  in  the  stomach. 

In  cyanide  poisoning  the  characteristic  odour  may  be 
observed  by  those  with  a  trained  sense  of  smell.  Similarly 
in  poisoning  with  chloral,  sulphonal  and  chloroform. 

The  appearances  in  cases  of  vegetable  poisoning  are  in 
no  case  very  characteristic.  Search  should  be  made  in  the 
intestinal  tract  for  the  presence  of  seeds,  leaves,  or  other 
evidence  of  vegetable  tissue. 

In  cases  of  meat  poisoning,  cultures  should  be  made  from 
the  intestinal  contents  and  from  the  spleen.  Blood  should 
be  removed  in  order  to  test  the  serum  against  various  micro- 
organisms for  the  presence  of  specific  agglutinins  (see  p.  374). 


MEDICO-LEGAL  POST-MORTEMS  315 


SPECIMEN  POST-MORTEM  REPORTS 

The  following  are  typical  post-mortem  reports  in  the  form 
in  which  they  should  be  sent  to  the  Procurator-Fiscal : — 


EDINBURGH,  ^th  June  1909. 

WE  hereby  certify  on  soul  and  conscience,  that  by  instructions 
of  the  Procurator-Fiscal  of  the  County  of  Midlothian,  on 

SATURDAY,  $rdjune  1909, 

in  the  Mortuary  of  Edinburgh  Castle,  we  examined  the  body 
of  a  man  which  was  identified  in  our  presence  by 

Sergeant  JOHN  SMITH, 
and  by  one  of  us, 

Captain  JONES,  R.A.M.C., 

as  that  of 

Private  JAMES  SCOTT. 

The  body  was  that  of  a  well-built  muscular  man,  7o|  inches 
in  height,  and  apparently  about  thirty-five  years  of  age.  The 
body  showed  no  signs  of  putrefaction,  and  the  usual  post- 
mortem rigidity  and  lividity  were  present. 

Situated  on  the  right  side  of  the  chest,  and  in  a  line  drawn 
between  the  junction  of  the  collar  bone  and  breast  bone  above 
and  the  right  nipple  below,  there  was  a  linear  wound  one  and 
a  half  inches  in  length,  the  edges  of  which  had  been  brought 
together  by  means  of  three  stitches.  The  upper  extremity  of 
this  wound  was  distant  one  and  a  half  inches  and  the  lower 
end  two  and  a  quarter  inches  from  the  middle  line  of  the  body. 
This  wound  was  found,  in  the  first  instance,  by  means  of  a 
blunt  probe,  and  subsequently,  during  the  course  of  the  dissec- 
tion, to  proceed  obliquely  through  the  second  intercostal  space 
downwards,  backwards,  and  towards  the  left  side,  and  to  pass 
through  the  upper  lobe  of  the  right  lung  near  its  anterior 


3i6  MEDICO-LEGAL  POST-MORTEMS 

margin,  into  the  pericardium,  and  finally  to  enter  the  right 
auricle  of  the  heart  above  the  auricular  appendage  and  close  to 
the  junction  of  the  superior  vena  cava  with  the  auricle.  The 
length  of  the  wounds  in  the  lung  and  pericardium  was  one 
inch,  and  that  in  the  auricle  half  an  inch. 

With  the  exception  of  the  injury  above  described,  the  body 
presented  no  marks  of  external  violence. 

The  right  pleural  cavity  was  full  of  coagulated  blood.  The 
right  lung  was  collapsed  and  bloodless.  The  left  lung  was 
healthy.  The  heart  contained  some  coagulated  blood,  and 
with  the  exception  of  the  wound  in  the  right  auricle,  was 
normal. 

The  liver,  spleen,  kidneys,  and  other  abdominal  organs 
presented  normal  appearances. 

The  stomach  contained  a  quantity  of  green  bilious  fluid. 
Its  mucous  membrane  was  in  the  condition  of  chronic  catarrh. 

The  mouth,  upper  air-passages  and  trachea  were  healthy. 

The  brain  and  its  membranes  were  congested,  but  other- 
wise they  were  normal. 

From  the  foregoing  examination  we  are  of  opinion  that 
death  was  due  to  loss  of  blood  from  a  wound  of  the  heart 
produced  by  a  sharp,  pointed  instrument. 

Signed  by  the  two  medical  men 
present  at  the  post-mortem. 


B 

EDINBURGH,  2otk  May  1897. 

WE    hereby    certify    upon    soul    and    conscience,    that    we 
yesterday, 

THURSDAY,  zoth  May  1897, 

examined,  in  the  Royal  Infirmary,  the  body  of  a  man,  which 
was  identified  in  our  presence  by 


MEDICO-LEGAL  POST-MORTEMS  317 

the  Wife  of  the  deceased, 
by  a  Police  Constable,  and  by  the 
House  Surgeon  attending  the  case, 
as  that  of 

THOMAS  ROBINSON. 

Deceased  was  an  able-bodied  person,  apparently  about 
sixty  years  of  age.  The  only  mark  of  violence  observable  was 
a  lacerated  wound  of  the  nose,  situated  on  the  prominence, 
and  about  a  quarter  of  an  inch  in  length.  Its  edges  were 
somewhat  swollen  and  gaping.  It  was  partially  covered  with 
a  soft  scab.  The  root  of  the  nose  was  also  somewhat  swollen. 

The  various  cavities  and  their  contents  were  carefully 
examined  ;  but  with  the  exception  of  marked  congestion  of  the 
spinal  cord,  and  the  effects  of  the  wear  and  tear  of  life,  nothing 
unusual  was  detected. 

Portions  of  the  heart,  liver,  and  kidneys  were  subjected  to 
examination  by  the  microscope.  They  were  all  more  or  less 
fatty,  but  not  to  a  great  extent. 

We  are  of  opinion  that  the  cause  of  death  in  this  case  was 
acute  congestion  of  the  spinal  cord,  such  as  we  are  conversant 
with  in  fatal  cases  of  Tetanus. 

Signed  by  the  two  medical  men 
present  at  the  post-mortem. 


APPENDIX    A 


TREATMENT  OF  SPECIMENS  FOR  MOUNTING 

Fixatives. — In  many  cases  the  pathologist  will  meet  with 
specimens  which  he  wishes  to  preserve  for  purposes  of 
further  examination,  reference,  or  teaching.  It  is  his  object 
to  keep,  as  far  as  possible,  the  form  of  the  organ  or  part 
and  its  natural  colour.  For  this  purpose  the  tissue  must  be 
fixed.  The  best  all-round  fixative  is  certainly  formalin,  but 
by  itself  it  does  not  penetrate  well,  and  the  colour  is  not  well 
preserved.  Salts  of  various  kinds  should  be  mixed  with  it. 
The  resulting  fluids  are  variously  known  as  Pick's,  Jores's,  and 
Kaiserling's  solutions.  The  formulae  for  making  up  these  are 
given  on  pp.  322-3.  Of  the  three,  probably  Pick's  solution 
costs  least  to  prepare.  There  is,  however,  little  to  choose 
between  them  as  regards  results.  The  explanation  underlying 
the  preservation  of  the  colour  of  the  organ  in  the  case  of  all 
three  is  as  follows  :  the  oxyhaemoglobin  is  transformed  by  the 
formalin  into  acid  haematin  which  has  a  brown  colour ;  this, 
under  the  influence  of  the  alcohol,  becomes  alkaline  haematin, 
which  has  a  bright  red  colour  so  like  the  original  oxyhaemo- 
globin that  the  natural  colour  appears  to  have  returned. 

Method  of  preparing  Specimens. — The  specimen  is  placed 
in  this  fluid  after  having  been  cut  open,  or  after  having  the 
fluid  injected  into  it,  the  object  being  to  secure  the  penetration 
of  the  organ  or  part  by  the  fluid  so  as  to  prevent  subsequent 
shrinkage  or  deformity.  Specimens  are  treated  differently 
according  to  their  nature  and  consistence.  It  should  always 
be  remembered  that  a  large  excess  of  fluid  is  necessary  for 
proper  fixation. 

319 


320  APPENDIX  A 

Solid  Organs. — There  are  two  ways  of  dealing  with  solid 
organs,  such  as  liver  and  spleen,  if  it  is  desired  to  preserve 
the  organ  whole.  Fixative  must  either  be  injected  into  the 
main  vessel — in  the  case  of  the  liver,  the  portal  vein — or  the 
fluid  is  injected  here  and  there  into  the  substance  of  the 
organ  with  a  syringe. 

In  most  cases  it  is  not  necessary  to  preserve  the  whole 
organ,  in  which  case  the  best  way  is  to  cut  it  into  a  series  of 
parallel  slices  about  an  inch  thick.  In  the  case  of  the  kidney 
it  is  sufficient  to  open  up  the  organ  in  the  usual  way.  The 
brain  is  best  injected  through  the  large  arteries  at  the  base. 
In  the  case  of  superficial  exudates  in  the  meninges  or  else- 
where some  stronger  formalin  may  be  smeared  over  the 
surface  so  as  at  once  to  fix  the  material.  When  dealing  with 
large  tumours,  it  is  well  to  inject  fluid  with  a  syringe  here  and 
there,  more  especially  in  the  softer  parts. 

Groups  of  Organs. — When  dealing  with  a  group  of  organs, 
it  may  be  necessary  to  fix  them  prior  to  removal.  This  can 
be  done  by  injecting  fixative  into  the  circulation  through  one 
of  the  carotids  or  into  a  main  vessel  going  to  the  part. 

Lungs. — In  the  case  of  the  lungs,  it  is  best  to  inject  the 
fluid  into  the  bronchi,  and,  in  addition,  into  any  cavity  or  area 
of  softening,  before  opening  up  the  organs.  If  they  have 
already  been  opened,  it  is  usually  sufficient  to  immerse  each 
half  in  fixative. 

Cysts. — When  dealing  with  cysts,  such  as  hydronephrosis, 
pyonephrosis,  hydatid  cysts,  etc.,  the  greater  part  of  the  fluid 
in  the  cyst  should  be  removed  with  a  syringe  and  replaced  by 
fixative. 

Intestine. — Portions  of  the  intestine  should  either  be  opened 
up,  washed,  laid  flat  or  pinned  out  flat,  and  immersed  in 
fixative  ;  or  they  may  be  washed  out  by  running  water  through 
them,  then,  having  tied  one  end,  fixative  is  poured  in  at  the 
upper  end,  the  upper  end  tied,  and  the  whole  immersed  in 
fluid.  This  latter  method  is  more  especially  adapted  to  the 
preservation  of  tumours,  the  bowel  being  subsequently  slit  up 
into  two  halves,  as  has  been  done  in  the  case  of  Fig.  69. 

Time  necessary  for  Fixation. — As  regards  the  time  during 
which  specimens  should  remain  in  the  fixative,  this  depends 
upon  their  size  and  consistence.  Thin  tissues,  such  as 


APPENDIX  A  321 

intestines  treated  as  above,  are  fixed  in  twenty-four  hours. 
Lungs  injected  through  the  bronchi,  and  brains  injected 
through  their  vessels,  will  be  fixed  sufficiently  for  cutting  in 
forty-eight  hours.  It  is  necessary,  however,  to  leave  the 
slices  some  time  longer  in  the  fixative.  For  more  solid  organs, 
such  as  liver,  kidney,  spleen,  or  heart,  ten  days  to  three  weeks 
will  usually  suffice,  but  the  specimens  take  no  harm  from 
remaining  considerably  longer.  A  good  test  as  to  whether 
or  no  an  organ  is  fixed  is  to  squeeze  it.  If  red  blood  exude, 
it  is  well  to  leave  the  specimen  some  time  longer.  Another 
test  is,  of  course,  the  consistence  of  the  organ.  As  a  rule,  so 
long  as  it  is  soft,  further  fixation  is  required. 

Mounting  Fluid. — When  properly  fixed,  the  organ  is 
washed  in  clean  water  for  some  minutes  and  placed  over- 
night in  methylated  spirit,  which  may  have  been  previously 
used.  It  is  then  placed  in  fresh,  clean  spirit,  until  the  colour 
has  returned  ;  a  few  hours  is  usually  sufficient.  The  specimen 
is  then  washed  again  in  running  water  for  a  few  minutes,  and 
placed  in  the  following  fluid  : — 

Glycerine  (pure)         .          .  I  part. 

Water       .          .          .          .          .2  parts. 

To  each  Winchester  quart  of  the  above,  I  fluid  oz.  of  formalin 
(40  per  cent)  is  added,  also  I  oz.  of  a  saturated  solution  of  pure 
potassium  acetate.  The  object  of  the  formalin  is  to  prevent 
the  growth  of  mould.  This  fluid  should  be  changed  once  or 
twice,  and  when  the  specimen  is  finally  mounted  in  a  glass 
jar,  the  same  fluid  should  be  filtered  in.  In  such  a  fluid  a 
specimen  will  remain  soft  and  retain  its  natural  colour  for 
many  years.  Care  should,  however,  be  taken  not  to  expose 
the  specimen  to  direct  sunlight,  otherwise  fading  of  the  colour 
will  occur. 

Mounting. — When  selecting  a  jar  for  permanent  mounting, 
the  nature  and  size  of  the  specimen  will,  of  course,  be  taken 
into  consideration.  As  a  rule,  the  rectangular  glass  jars  are 
the  best,  the  specimen  being  fixed  to  one  side  of  the  jar  by 
means  of  a  little  gelatine,  or  secured  to  a  plate  of  glass 
with  strong  thread.  Whole  hearts  and  spleens  are  best  sus- 
pended in  round  jars.  Portions  of  intestine  laid  open  can 


322  APPENDIX  A 

be  stretched  upon  sheets  of  glass  or  mica,  or  within  a  frame 
formed  of  a  bent  glass  rod.  The  interior  of  cavities  and  the 
"surfaces  of  organs  are  best  coated  with  gelatine  fluid,  which  is 
prepared  as  follows,  in  order  to  prevent  portions  coming  away 
and  producing  turbidity  : — 

100  grains  pure  gelatine 

800  c.c.  thymol  water  (saturated  in  the  cold) 

200  c.c.  glycerine. 

This  is  gently  heated  until  the  gelatine  melts.  A  few  drops 
of  acetic  acid  are  added,  and  the  whole  is  clarified  with  white 
of  egg.  The  gelatine  is  poured  upon  the  specimen  while 
warm  and  fluid  and  allowed  to  solidify  before  the  specimen  is 
mounted.  For  fixing  on  the  cover  of  the  jar  the  best  medium 
is  a  mixture  of  litharge  and  Archangel  tar  in  quantities 
sufficient  to  make  a  thick  paste.  A  band  of  Berlin  black 
should  then  be  painted  round  the  margin  of  the  cover. 

Summary  of  Steps  in  Treatment  of  Specimens 
for  Mounting 

1.  Place    in    Pick's,   Jores's,    or   Kaiserling's   fixative   (for 
composition  see  below)  for  a  variable  period  depending  upon 
size,  consistence,  etc.,  of  specimen. 

2.  Wash  in  clean  water  for  some  minutes. 

3.  Place  overnight   in  methylated   spirit  which   has  been 
previously  used. 

4.  Transfer    to  fresh  spirit   for  a  few  hours    until   colour 
returns. 

5.  Wash  in  running  water  for  a  few  minutes. 

6.  Place  in  glycerine  and  water  (one  part  of  the  former  to 
two  of  the  latter),  to  which  potassium  acetate  ('i   ounce  sat. 
sol.  to  Winchester  quart)  is  added,  also  formalin  to  prevent 
the  growth  of  moulds. 

7.  Mount  in  fresh  fluid  of  similar  composition. 

Pictts  Fixative 

Formalin  (pure,  i.e.  40  per  cent)     .          .      50  c.c. 
Artificial  Carlsbad  salt  .          .          .          .50  grm. 
Distilled  water      .  .      j  litre. 


APPENDIX  A  323 

The  Carlsbad  salt  is  prepared  by  mixing  Sod.  sulphate  22 
parts,  Sod.  bicarb.  18  parts,  Sod.  chloride  9  parts,  Pot. 
sulphate  i  part.  The  last  ingredient  is  not  essential. 

Kaiserling's  Fixative 
Formalin      ......      100-200  c.c. 

Pot.  nitrate  .          .          .          .          .  15  grm. 

Pot.  acetate  .          .          .          .          -3°  grm- 

Water  ......      I  litre. 

Jores*s  Fixative 
Formalin      .          .          .          .          .          .50-100  c.c. 

Mag.  sulph.  .          .          .          .          .20  grm. 

Sod.  sulph.  ......      20  grm. 

Sod.  chloride         .          .          .          .          .10  grm. 

Water  .          .          .         .          .          .      i  litre. 

In  each  case  to  obtain  the  best  results  the  formalin  used  should 
be  Schering's.  It  costs  about  twice  the  price  of  the  ordinary 
commercial  formalin,  but  it  is  greatly  superior  in  quality. 

The  salts  for  the  various  fixatives  may  be  made  up  in 
packets  and  mixed  with  the  water  and  formalin  as  required. 

In  the  case  of  each  of  the  methods,  after  fixation  is 
complete  the  specimen  is  transferred  to  methylated  spirit  in 
which  the  acid  haematin  becomes  alkaline  and  the  colour  thus 
returns  to  the  blood  in  the  tissue. 

After  twenty-four  hours  in  spirit  the  specimen  is  placed  in 
a  preservative  which  in  each  instance  contains  glycerine  as 
its  principal  ingredient.  As  a  rule  the  glycerine  is  diluted 
with  double  the  quantity  of  water  to  which  potassium  acetate 
(in  the  case. of  Pick's  and  Kaiserling's  method)  is  added. 

Recently  Mr.  R.  Frost  of  Sheffield  (Proc.  Path.  Soc.  Great 
Britain  and  Ireland,  Jan.  1912)  has  proposed  the  following  as 
a  preserving  medium  : — 

Sod.  fluoride          .          .          .          .          .80  grm. 
Chloral  hydrate     .          .          .          .          .80  grm. 

Pot.  acetate 160  grm. 

Cane  sugar  (Tate's  cube)        .          .          .3500  grm. 
Thymol  water  (saturated)       .          .          .8  litres. 

The  chief  advantage  of  this  medium  is  its  cheapness. 


324  APPENDIX  A 

TREATMENT  OF  TISSUES  FOR  MICROSCOPIC 
PURPOSES 

Necessity  for  Routine  Microscopic  Examinations 

For  a  complete  investigation  of  a  fatal  case  of  disease,  it  is 
necessary  not  only  to  examine  as  many  parts  of  the  body  as 
possible  with  the  unaided  eye,  but  to  investigate  them  further 
by  means  of  the  microscope.  This  routine  examination  of  the 
organs  microscopically  cannot  be  too  strongly  insisted  upon. 
Where  only  specimens  of  exceptional  interest  are  put  through  and 
cut,  the  pathologist  will  never  be  able  to  acquire  skill  in  differ- 
entiating the  finer  shades  of  pathological  change.  Further, 
diseased  tissues  do  not  always  bear  their  secrets  stamped 
upon  them  plainly,  and  unless  a  microscopic  examination  is 
carried  out  as  a  matter  of  routine,  much  that  is  of  exceptional 
interest  will  be  lost. 

Selection  of  Portions  of  Organs  or  Tissues 

As  regards  selection  of  a  portion  of  a  diseased  organ,  no 
definite  rules  can  be  laid  down.  It  is  well  not  to  be  satisfied  with 
a  single  portion,  but  to  take  several  pieces  from  different  parts. 
Where  one  is  dealing  with  a  tumour,  one  section  should  include 
the  capsule  or  a  portion  of  any  invaded  tissue.  If  the  tumour 
be  in  the  bowel,  along  with  the  portion  should  be  taken  a  piece 
of  the  normal  gut  wall.  In  the  case  of  such  organs  as  kidney, 
liver,  and  spleen,  one  section  at  any  rate  should  include  the 
capsule.  Sections  of  the  kidney  should  of  course  include  both 
cortex  and  medulla. 

It  is  not  at  all  a  bad  plan  to  cut  the  different  organs  in 
different  ways,  or  at  any  rate  to  pare  them  down  to  different 
shapes  after  they  have  been  passed  into  spirit.  Thus,  kidney 
may  be  cut  as  a  triangle,  the  base  being  the  capsule,  liver  cut 
in  squares,  and  spleen  in  the  form  of  a  rectangle.  The 
advantage  of  this  method  is  that  afterwards,  when  the  tissues 
are  being  passed  through  the  various  reagents  and  also  when 
in  paraffin,  they  may  be  recognised  at  a  glance. 

In  any  case,  the  section  of  the  organ  should  be  thin.      It 


APPENDIX  A  325 

cannot  well  be  too  thin.  A  good  average  thickness,  except 
for  certain  purposes,  is  -|  inch.  In  the  case  of  tissue  which  is 
to  be  fixed  in  such  mixtures  as  Flemming's  or  Marchi's  still 
thinner  sections  are  required.  This  does  not  mean  that  the 
pieces  of  tissue  must  not  be  large.  Asa  matter  of  fact,  it  is 
most  advantageous  to  have  large  sections,  although  they  are 
much  more  difficult  to  cut  with  the  microtome.  In  the  case 
of  lung  preparations,  it  may  be  safely  said  that  the  sections 
cannot  be  too  large.  It  is  exceedingly  difficult,  if  not  im- 
possible, to  judge  of  the  nature  and  distribution  of  pulmonary 
diseases  from  a  minute  portion  of  lung  taken  out  at  random. 

These  statements  do  not  apply  to  sections  for  all  purposes. 
When  examining  minute  changes  by  serial  sections,  it  is 
well  to  have  small  pieces  for  cutting,  because  it  is  obviously 
much  more  easy  to  find  corresponding  areas  in  the  sections 
above  and  below  any  given  point  if  the  portion  of  tissue  is 
minute. 

When  dealing  with  portions  of  the  bowel,  it  is  well  to  pin 
out  a  fairly  large  area  of  intestine  upon  a  small  block  of  wood 
and  immerse  both  in  the  fixative.  Subsequently,  smaller 
portions  may  be  cut  or  snipped  out.  For  any  of  the  above 
purposes  a  sharp  scalpel  or  razor  is  required.  In  certain  cases 
it  may  be  advisable  to  fix  the  specimen  entire  before  cutting 
away  any  portion  for  microscopic  examination.  This  par- 
ticularly applies  to  tumours  of  the  stomach  and  bowel.  In 
any  case,  it  never  spoils  a  specimen  neatly  to  cut  out  a  small 
piece  for  microscopic  purposes. 

It  is  well  at  the  same  time  as  one  takes  the  sections  to 
make  a  note  of  any  matter  of  importance  upon  the  label  of  the 
bottle  in  which  the  tissues  are  to  be  placed,  such  as  the  part  of 
the  organ  from  which  the  specimen  was  taken.  Instead  of 
pasting  it  on  the  bottle,  the  label  written  in  pencil  may  be 
placed  inside  the  bottle  along  with  the  specimens. 

Fixation  of  Tissue 

It  is  impossible  to  cut  in  the  fresh  condition  sections  of 
organs  thin  enough  for  microscopic  purposes.  Parenchy- 
matous  cells  and  softer  parts*  fall  out,  leaving  a  mere 
skeleton  of  fibrous  tissue.  It  is  necessary  therefore,  in  the 


326  APPENDIX  A 

first  place,  to  fix  the  tissue.  There  are  many  fixatives  for 
tissues,  but  for  ordinary  purposes  10  per  cent  formalin  (i.e. 
10  per  cent  of  the  commercial  40  per  cent  formaldehyde) 
is  probably  the  best.  It  is  readily  procured  and  made  up, 
penetrates  well,  and  gives  excellent  results.  For  this  purpose 
undoubtedly  Schering's  formalin  is  the  best.  With  other  brands, 
costing  less,  precipitates  are  very  apt  to  form,  especially 
in  tissues  containing  much  blood.  For  certain  purposes  other 
fixatives  may  be  employed,  and  as  a  matter  of  fact,  when 
dealing  with  cases  of  special  interest,  it  is  well  to  use  more 
than  one  fixative.  One  of  the  advantages  of  formalin  is  that 
other  methods  of  fixation  can  be  employed  subsequently,  such 
as  bichromate  of  potash  and  osmic  acid  ;  another  is  that  sections 
can  be  placed  in  gum,  frozen,  and  cut  directly  from  the  formalin 
solution.  As  in  all  methods  of  fixation,  it  is  essential  to  have 
plenty  of  fluid — at  least  twenty  volumes  of  fluid  to  one  of 
tissue. 

Treatment  of  Tissue  for  cutting  in  Gum 

Suitable  portions  of  tissue  are  placed  in  the  10  per  cent 
formalin,  and  are  left  for  twenty-four  hours.  In  the  case  of  thick 
pieces,  it  is  well  to  leave  them  longer.  At  the  end  of  that  time, 
if  a  rapid  diagnosis  is  required  or  if  it  is  necessary  to  stain  for 
the  presence  of  fat,  pieces  of  the  organs  can  be  transferred 
directly  from  the  formalin  to  a  gum  solution  made  up  as 
follows  : — 

Gum  Arabic         .          .      i  part, 
Water          .          .          .3  parts, 
Thymol,  a  few  crystals, 

and  subsequently  frozen  and  cut. 

Although  good  results  are  obtained  by  cutting  directly  after 
fixation  in  formalin  it  is  better  to  harden  in  spirit  for  24  hours 
or  longer,  to  wash  out  the  spirit  in  running  water  overnight, 
and  subsequently  to  place  in  gum  solution  for  some  hours. 

Other  Methods  of  Fixation 

i.  For  the  brain,  cord,  or  other  portion  of  the  nervous 
system,  where  it  is  desired  to  preserve  the  myelin  sheath  of 


APPENDIX  A  327 

the  nerve  elements,  it  is  necessary  to  fix  the  myelin  substance 
by  bichromate  of  potassium  or  other  similar  salt.  For  this 
purpose,  Miille^s  fluid  is  as  good  as  many  others  of  more 
recent  introduction.  It  is  made  up  as  follows  : — 

Bichromate  of  potassium  .          .      2-5  grm. 

Sulphate  of  sodium  .          .  I  grm. 

Water    .          .          .          .          .          .100  c.c. 

The  sodium  sulphate  of  the  Miiller's  fluid  may,  according  to 
Mann,  be  omitted  without  the  solution  suffering  as  a  fixative. 

Portions  of  brain  or  cord  may  be  placed  in  this  direct  or, 
better,  transferred  to  it  from  formalin.  They  should  be  left  in 
the  fluid  for  six  to  eight  weeks,  washed  thoroughly  in  running 
water  for  some  hours,  and  transferred  first  to  50  per  cent 
spirit,  then  75  per  cent,  lastly  pure  spirit.  The  bichromate 
fluid  should  be  changed  freqitently  during  the  process  of 
fixation.  The  process  can  be  hastened  considerably  by 
placing  the  fixative  containing  the  pieces  of  cord  in  the 
incubator  at  37°  C. 

Although  tedious,  the  above  method  gives  very  good 
results,  even  with  specimens  which  have  to  be  stained  with 
ordinary  methods.  Miiller's  fluid  also  forms  the  basis  of  a 
number  of  other  fixation  methods,  so  that  it  is  advisable  to 
keep  it  in  considerable  quantity  in  stock. 

2.  Zenker's  Fluid. — This  can  be  made  from  Miiller's  fluid  by 
adding  corrosive  sublimate,  5  grams,  and  glacial  acetic  acid, 
5  c.c.  to  every  100  c.c.  It  is  advisable  to  add  the  acetic  acid 
as  required  to  the  quantity  of  stock  solution  used,  as  it  readily 
evaporates  if  kept.  The  tissues  should  be  fixed  in  the  above 
for  twelve  to  twenty-four  hours.  At  the  end  of  that  time  wash 
in  running  water  for  some  hours  and  place  in  methylated  spirit 
till  required. 

This  is  an  exceedingly  good  method  of  fixation  for  most 
purposes.  The  solution  penetrates  well  and  preserves  nuclear 
structure  admirably.  One  objection  which  it  has  in  common 
with  all  mercury  fixatives  is  that  the  mercury  becomes  pre- 
cipitated in  the  tissues.  This  can  be  removed  by  means 
of  iodine,  which  forms  with  it  a  colourless  soluble  compound. 
The  iodine  may  be  added  to  the  spirit  in  which  the  tissues  are 


328  APPENDIX  A 

preserved,  or,  what  is  a  better  way,  the  sections  may  be  treated 
with  Lugol's  fluid  (see  p.  350)  or  a  I  per  cent  alcoholic 
solution  of  iodine  for  ten  to  twenty  minutes  before  staining, 
followed  by  treatment  with  spirit  to  remove  the  iodine. 

3.  OrtWs  Fluid. — This  is  simply   Miiller's  fluid   in   which 
10  c.c.  pure  commercial   formalin   is   added   to   the   100   c.c. 
The  formaldehyde  should  be  added  immediately  before  the  fixa- 
tive is  used.      Fixation  is  complete  in  three  to  four  days.     The 
specimens  are  afterwards  washed  in  running  water,  and  placed 
in  methylated  spirit.      Mallory  states  that  the  addition  of  5  per 
cent  acetic  acid  improves  the  fluid.     The  fluid  is  an  excellent 
fixative  for  most  purposes. 

4.  March? s  Fluid. — This  is  Miiller's  fluid  two  parts,  to  osmic 
acid  ( i  per  cent  aqueous  solution)  one  part.    '  As  in  the  case  of 
all  osmic    acid    fixatives   the    sections   should   be    very    thin. 
They  should  remain  in  the  fluid  three  days  protected  from  light. 
They  are  afterwards  washed  in  running  water  and  hardened  in 
spirit.      The  method  is  specially  applicable  to  the  demonstra- 
tion of  recent  areas  and  tracts  of  degeneration  in  the  spinal 
cord  and  brain  (see  p.  356). 

5.  Flemmings  solution  is  made  up  as  follows  : — 

Osmic  acid  2  per  cent  aqueous  solution          .        4  parts. 
Chromic  acid  I  percent     ,,          ,,  .      15     ,, 

Glacial  acetic  acid      .....        i  part. 

The  portions  of  tissue  should  be  exceedingly  thin,  as  the 
osmic  acid  penetrates  badly.  They  are  left  in  the  fluid  for  one 
to  three  days  in  the  dark,  subsequently  washed  in  water,  and 
hardened  in  spirit.  The  method  is  specially  applicable  to  the 
study  of  nuclear  changes,  and  to  the  demonstration  of  olein  fats. 

6.  Corrosive    sublimate,    a    saturated    solution    in    normal 
saline  with,  if  desired,  the  addition  of  5  per  cent  glacial  acetic 
acid.      The  tissues  are  fixed  for  twelve  to  twenty-four  hours, 
washed  thoroughly  in  water  and  hardened  in  spirit.     This  is  an 
exceedingly   good    all-round  fixative.      More    especially  is   it 
applicable    to   the   fixation    of   tissues   when   it   is   desired  to 
demonstrate  granules  in  the  leucocytes  and  other  cells.     The 
same  objection  as  in  the  case  of  Zenker's  fluid  holds  good  with 
corrosive  sublimate.     The  sections  must  be  treated  with  iodine 
before  staining  in  order  to  dissolve  the  mercury. 


APPENDIX  A  329 

7.  Absolute  alcohol  and  methylated  spirit  are  both  fixa- 
tives as  well  as  hardening  agents.  Under  their  influence, 
however,  the  tissues  and  cell  elements  tend  to  shrink  consider- 
ably. They  are  said  to  be  specially  good  for  tissues  in  which 
it  is  desired  to  demonstrate  bacteria.  But  as  a  matter  of  fact 
formalin  and  corrosive  sublimate  are  equally  as  good. 

It  is  always  desirable  to  place  a  little  cotton-wool  in  the 
bottle  in  which  the  fixation  is  carried  out,  in  order  to  prevent 
sections  adhering  to  the  bottom.  It  is  also  desirable,  parti- 
cularly when  dealing  with  unconsolidated  lung,  to  place  some 
at  the  top,  in  order  to  prevent  the  pieces  of  tissue  from  float- 
ing. Remember  always  to  have  a  large  excess  of  fluid 
present. 

Sending  Material  to  a  Distance 

The  practitioner  not  infrequently  desires  to  send  pathological 
material  to  some  institute  or  hospital  where  expert  opinion  can 
be  obtained.  For  this  purpose  the  best  fluid  in  which  to  place 
the  tissue  is  10  per  cent  formalin.  The  pieces  of  tissue  should 
be  small,  and  at  least  ten  times  as  much  fluid  as  tissue  should 
be  present  in  the  bottle,  otherwise  penetration  of  the  fixative 
will  be  incomplete  and  putrefactive  processes  will  progress. 
In  the  absence  of  formalin,  methylated  spirit  or  absolute 
alcohol  may  be  used. 

Treatment  after  Fixation 

After  fixation  is  complete,  as  a  rule  it  is  advisable  to  wash 
the  tissue  in  running  water.  This  is  absolutely  necessary  when 
fixatives,  such  as  Zenker's,  Orth's  fluid,  corrosive  sublimate, 
Flemming's,  have  been  used.  It  is  not  necessary  in  the  case 
of  formalin-fixed  tissue.  The  latter  may  be  placed  directly  in 
methylated  spirit. 

Hardening. — After  fixation,  or  if  necessary  after  fixation  and 
washing,  the  tissue  is  placed  in  methylated  spirit.  This  can 
be  done  by  placing  directly  in  commercial  methylated  spirit  or 
by  passing  through  dilutions  (50  per  cent  and  70  per  cent) 
first.  For  ordinary  purposes  the  dilutions  may  be  omitted, 
especially  when  one  is  dealing  with  material  removed  from 
the  body  twenty-four  or  forty-eight  hours  after  death.  When 


330  APPENDIX  A 

it  is  desired  to  preserve  the  finer  details,  more  especially  when 
one  is  dealing  with  the  central  nervous  system,  then  passage 
through  the  dilutions  is  advisable,  as  there  will  probably  be 
somewhat  less  shrinkage  in  the  cell  elements.  In  addition  to 
hardening  the  specimen,  the  passage  through  spirit  also  to  a 
certain  extent  dehydrates. 

Dehydration. — The  next  process  is  dehydration,  or  the 
removal  of  all  water  from  the  tissue.  Some  tissues  are  more 
difficult  to  dehydrate  than  others.  As  a  rule  the  denser  the 
tissue  the  more  difficult  it  is  to  dehydrate.  For  this  reason 
any  specimen  containing  well-formed  connective  tissue  requires 
longer  than  a  specimen  such  as,  for  example,  normal  liver. 
For  purposes  of  dehydration  it  is  well  to  use  two  changes  of 
absolute  alcohol.  As  a  rule,  a  few  hours  in  the  first  alcohol 
and  twenty-four  hours  in  the  second  is  sufficient.  The  alcohol 
must  be  replaced  by  fresh  after  being  used  for  a  succession  of 
specimens  during  a  few  days. 

Embedding 

The  further  treatment  of  the  specimen  depends  upon 
whether  one  wishes  to  cut  the  sections  in  paraffin  or  celloidin. 
In  the  case  of  most  organs  and  tissues,  it  is  necessary  to 
impregnate  with  some  substance  which  will  hold  together  the 
cellular  elements  during  the  process  of  cutting  and  staining. 
For  this  purpose,  paraffin  or  celloidin  is  commonly  employed. 
Each  has  its  own  special  advantages,  each  therefore  has  its 
supporters.  Probably  paraffin  is  more  generally  used,  so  we 
shall  consider  it  first. 

Embedding  in  Paraffin. — From  the  absolute  alcohol,  the 
sections  are  placed  in  a  clearing  fluid,  which  may  be  chloro- 
form, benzol,  xylol  or  some  such  chemical  substance,  benzol 
being  the  cheapest  of  those  mentioned.  All  these  have  this  in 
common  that  they  readily  mix  with  alcohol  on  the  one  hand, 
and  with  paraffin  on  the  other.  At  least  twenty-four  hours 
should  be  allowed  for  this  clearing  process,  and  it  is  well  to  use 
two  changes  of  the  clearing  medium. 

The  sections  should  then  be  transferred  to  benzol,  or  what- 
ever clearing  agent  is  employed,  to  which  some  pieces  of 
paraffin  have  been  previously  added,  and  the  bottle  placed  on 


APPENDIX  A  331 

the  top  of  the  paraffin  oven,  or  inside  the  incubator.  At  this 
temperature,  which  will  be  about  37°-4o°  C.,  benzol  will,  of 
course,  take  up  much  more  paraffin.  From  this  mixture,  at  the 
end  of  twenty-four  hours,  the  pieces  of  tissue  are  placed  in  a 
shallow  uncovered  dish  containing  pure  paraffin,  in  the  interior 
of  the  paraffin  oven.  Here  they  remain  until  all  the  benzol 
has  been  driven  off.  If  the  sections  are  not  too  thick  or  if 
they  are  turned  over  at  intervals,  a  few  hours  will  suffice.  It 
is  important  on  the  one  hand  not  to  leave  the  specimens  too 
long,  because  the  heat  of  the  oven  shrivels  them.  On  the 
other  hand,  it  is  necessary  to  drive  off  all  the  benzol,  else  the 
tissue  will  shrivel  afterwards  and  will  not  cut  well.  As  a  rule, 
if  they  are  placed  in  the  pure  paraffin  (melting-point  50°- 5 3°  C.) 
the  first  thing  in  the  morning,  they  may  be  cast  the  same  day, 
some  time  during  the  afternoon.  The  criterion  for  the  whole 
of  the  benzol  having  been  driven  off  is  the  absence  of  the  char- 
acteristic odour  on  shaking  the  dish  containing  the  pieces  of 
tissue. 

To  cast  the  specimens,  two  L-shaped  moulds  are  placed 
upon  a  porcelain  slab,  so  as  to  shut  in  a  space  the  size  of 
which  will  vary  with  the  number  and  size  of  the  specimens. 
Melted  paraffin  from  a  large  dish  is  then  poured  in,  to  the 
depth  of  about  i  centimetre,  the  specimens  are  transferred  by 
means  of  a  warm  pair  of  forceps,  and  placed,  according  to  the 
direction  in  which  it  is  desired  to  cut  them,  in  the  fluid  paraffin 
upon  the  porcelain  slab.  When  the  surface  of  the  paraffin  has 
solidified,  slab,  paraffin  and  moulds  may  be  placed  in  cold 
water  and  the  blocks  removed  when  solidification  is  complete. 

The  above  periods  for  dehydration,  clearing,  etc.,  may  be 
considerably  shortened  if  the  specimens  be  small  and  thin. 
Various  abridged  methods  are  in  use,  of  which  the  following  is 
a  reliable  one.  At  the  same  time,  it  must  be  remembered  that 
leisurely  methods  give  the  best  results. 

Quick  Method  for  embedding  in  Paraffin  (Mallory  and 
Wright). — Small  pieces  of  tissue  or  organ  are  placed  in  two 
changes  of  acetone  for  half  to  two  hours.  The  acetone  must 
be  in  large  excess.  From  this  they  are  transferred  to  xylol 
or  chloroform  for  fifteen  to  thirty  minutes.  They  are  then 
placed  in  pure  melted  paraffin  for  half  an  hour  to  an  hour  and 
a  half  at  57°  C.  Embed  in  paraffin. 


332  APPENDIX  A 


Summary  of  Method  of  embedding  in  Paraffin 

Fixation  in  formalin  for    .          .          .24  hours. 

Hardening  in  spirit  for  at  least.          .      24  ,, 

Absolute  alcohol,  two  changes  .          .      24-48  „ 
Benzol,     xylol,     or    chloroform,    two 

changes  .....      24  ,, 
Benzol,  etc.,   saturated   with  paraffin 

at  37°  C.           .          .          .          .24  „ 

Pure  paraffin,  melting-point  5o°-53°  C.        6-12  ,, 

Cutting  Preparations  embedded  in  Paraffin. — For  cutting 
sections  embedded  in  paraffin,  one  of  the  improved  rocking 
microtomes  made  by  the  Cambridge  Scientific  Instrument 
Company  is  probably  the  best.  No  special  knife  is  required. 
Suitable  razors  are  supplied  by  Milliard,  Edinburgh,  for  35. 
They  must  be  kept  in  good  order  by  frequent  stropping  and 
occasional  setting  on  a  Canadian  hone.  The  block  of  paraffin, 
in  which  the  specimen  has  been  cast,  is  pared  down  to  a  con- 
venient size  with  a  penknife.  It  is  fixed  to  one  of  the  dies, 
which  screws  on  to  the  arm  of  the  microtome,  by  means  of 
a  heated  piece  of  metal — the  end  of  a  copper  section-lifter  will 
do  admirably.  The  screw  regulating  the  thickness  of  the 
section  is  adjusted  to  the  desired  position  (about  10  microns), 
and  a  number  of  sections  are  cut.  These  can  be  lifted  by 
means  of  a  fine-pointed  pair  of  forceps  and  a  small  brush,  and 
placed  in  warm  water  about  44°  C.  When  the  sections  have 
flattened  out  they  are  mounted  singly,  or,  if  desired,  in  a 
series,  on  a  clean  slide.  Slides  previously  smeared  with 
albumin  (egg  albumin  in  water)  have  this  advantage,  that 
the  sections  adhere  to  them  more  firmly.  The  slide,  or  series 
of  slides,  is  then  placed  in  a  slanting  position  till  dry.  They 
are  then  placed  on  the  top  of,  or  in,  the  paraffin  bath,  or  in  an 
incubator  at  37°  C. 

Embedding  in  Celloidin. — The  sections  are  taken  from 
absolute  alcohol  and  placed  for  twenty-four  hours  in  a  mixture 
of  equal  parts  of  absolute  alcohol  and  ether.  From  this  they 
are  transferred  to  a  dilute  solution  (2  per  cent)  of  celloidin 
(Schering's  granular)  in  equal  parts  of  alcohol  and  ether. 


APPENDIX  A  333 

They  may  be  left  in  this  for  twenty-four  hours  or  longer,  and 
at  the  end  of  that  time  are  transferred  to  a  6  per  cent  solution 
of  the  same  material.  Here  they  remain  for  twenty-four  hours 
more. 

To  cast  the  specimens,  take  a  cube  of  wood  of  a  suitable 
size.  Pour  a  little  celloidin  over  the  cross-grained  surface, 
then  place  the  specimen  on  it  and  pour  a  little  more  over. 
Allow  the  whole  to  dry  till  it  is  of  a  firm  consistence,  then 
place  in  85  per  cent  methylated  spirit. 

The  celloidin  method  of  embedding  is  more  especially  used 
for  sections  of  the  brain,  spinal  cord,  bone,  and  skin,  but  it  is  ap- 
plicable to  all  types  of  tissue.  Its  chief  advantage  is,  that  during 
the  process  of  impregnating  the  specimen  with  the  celloidin 
no  heat  is  applied.  Another  advantage  which  it  has  over  the 
paraffin  method  is  that  the  sections  are  floated  in  the  staining 
fluids  and  not  fixed  to  slide  or  cover-glass.  This  allows  of  the 
stain  acting  from  two  surfaces,  and  undoubtedly  has  the  result 
of  giving  a  more  natural  appearance  to  the  tissue  elements. 

Cutting  Preparations  embedded  in  Celloidin. — For 
cutting  such  preparations  a  number  of  microtomes  are  avail- 
able. Among  them  the  Schanze,  Minot,  and,  for  large  sections, 
the  Bruce  microtome  are  the  best  known.  Special  knives  are 
always  supplied  with  these,  which  require  great  care  in  order 
to  keep  sharp. 

While  cutting,  the  specimen  and  the  knife  are  always  kept 
moist  with  80  per  cent  spirit,  applied  one  or  two  drops  at  a 
time  by  means  of  a  large  brush.  Serial  sections  may  be 
obtained  by  placing  the  sections  as  they  are  cut  upon  tissue 
paper  moistened  with  spirit.  The  sections  are  lifted  with  a 
brush,  and  placed  in  80  per  cent  spirit  until  they  must  be 
stained.  From  this  they  are  taken  and  either  washed  first  or 
placed  directly  in  the  staining  fluid. 

Cutting  Sections  in  Gum. — As  previously  stated,  it  is 
advisable  to  fix  specimens  before  cutting  them.  It  is  possible, 
however,  to  obtain  sections  good  enough  for  making  a 
diagnosis,  as,  for  instance,  at  an  operation  while  the  surgeon 
is  waiting,  by  placing  a  small  piece  of  tissue  in  gum  and 
immediately  cutting  it.  When  such  rapidity  is  not  demanded, 
twenty-four  hours'  fixation  in  10  per  cent  formalin  is  sufficient, 
but  where  time  permits,  and  when  it  is  not  desired  subsequently 


334  APPENDIX  A 

to  stain  for  fat,  it  is  well  in  addition  to  harden  the  tissue  in 
spirit  for  a  day  or  two.  This  should  not,  of  course,  be  done 
with  sections  which  are  subsequently  to  be  stained  for  fat.  At 
the  end  of  that  time  the  spirit  should  be  washed  out  in  running 
water  over  night,  and  the  specimen  placed  in  gum  for  some 
hours.  It  is  absolutely  necessary  to  wash  out  the  spirit 
thoroughly,  and  to  allow  sufficient  time  for  the  gum  to  pene- 
trate. Sections  cut  in  this  way  give  as  good  results  as  any. 
when  suitably  stained.  For  many  tissues,  notably  lung,  the 
results  are  as  good  as  those  obtained  with  the  best  celloidin 
sections,  and  the  tissues  are  less  subjected  to  the  influence  of 
chemicals,  and  in  consequence  are  less  shrunken.  Further, 
very  large  sections  can  be  obtained  by  freezing,  the  size  only 
being  limited  by  the  size  of  the  freezing  stage,  and  this,  as 
has  been  already  emphasised,  is  a  matter  of  supreme  import- 
ance in  studying  lung  disease.  Formerly,  when  ice  and  salt 
had  to  be  used  for  freezing,  the  method  was  clumsy.  Later, 
the  introduction  of  ether  simplified  the  process  ;  but  in  these 
days  of  liquid  CO2  no  method  of  cutting  sections  is  more 
simple  or  effective. 

With  regard  to  the  type  of  microtome,  the  Cathcart,  with 
ether  freezing,  is  a  useful  little  instrument,  particularly  for 
travelling  purposes,  when  the  pathologist  accompanies  the 
surgeon  to  an  operation. 

For  laboratory  purposes  undoubtedly  one  of  the  numerous 
CO2  freezers  is  preferable,  owing  to  its  more  rapid  and  more 
powerful  action.  Of  the  more  elaborate  CO2  microtomes,  the 
Aschoff-Becker  is  very  good.  A  simple  one  is  that  introduced 
by  Dr.  Mixter,  and  used  largely  in  America. 

The  piece  of  tissue  is  placed  upon  the  stage  of  the 
microtome,  and  some  gum  poured  on  the  top  and  round  it. 
The  carbonic  acid  gas  is  then  turned  on  and  off  a  number  of 
times  till  the  specimen  is  opaque,  white,  and  hard.  In  this 
condition  the  knife  will  not  cut  it,  but  when  it  is  just  com- 
mencing to  thaw  the  best  sections  will  be  obtained.  To 
prevent  the  deeper  portions  from  thawing,  the  gas  should  be 
turned  on  every  now  and  then.  A  razor,  the  blade  of  a 
carpenter's  smoothing-plane,  or  one  of  the  special  knives 
supplied  with  the  microtomes  is  used  for  cutting.  The 
sections  are  removed  with  a  brush  and  placed  in  a  basin  of 


APPENDIX  A  335 

cold  water,  where  they  will  gradually  flatten  out.  The  sections 
may  be  stained  at  once,  or  preserved  in  formalin  water,  or 
better,  in  spirit,  for  future  use.  When  it  is  desired  to  stain 
fat,  spirit  cannot  of  course  be  used. 

Decalcification 

Tissues  which  contain  bone  or  calcium  salts,  such  as 
atheromatous  patches  in  the  aorta,  calcareous  tuberculous 
glands,  etc.,  require  to  be  decalcified  before  being  cut, 
otherwise  the  razor  or  knife  employed  will  be  ruined. 
Before  decalcifying,  the  portion  of  bone  or  tissue  is  fixed, 
having  been  previously  sawn  or  cut  to  the  desired  size.  As 
fixative,  formalin  10  per  cent,  Zenker's  or  Orth's  fluid  may 
be  used.  After  washing,  the  specimen  is  placed  in  methylated 
spirit  for  at  least  twenty-four  hours. 

There  are  many  decalcifying  fluids,  the  chief  constituent 
being,  in  all  cases,  some  acid.  In  order  to  ensure  the  penetra- 
tion of  the  acid,  the  fluid  should  be  frequently  changed,  and 
should  be  used  in  large  quantity.  Unfortunately,  nuclei  are 
always  damaged  by  such  acids,  so  that  the  sections  require 
to  be  stained  for  longer  periods  and  never  give  quite  such 
good  results  as  tissues  which  are  not  so  treated. 

Nitric  acid  is  one  of  the  most  effective  decalcifying  agents. 
It  is  used  in  a  5  per  cent  aqueous  solution.  For  rapidity  of 
action  Perenny's  solution  can  be  strongly  recommended.  It 
is  made  up  as  follows  : — 

Nitric  acid,  10  per  cent .          .       •  .          .     400  c.c. 

Absolute  alcohol 300  c.c. 

Chromic  acid,  ^  per  cent         .          .          .      300  c.c. 

In  the  above  solution  decalcification  is  usually  complete,  if 
moderately  thin  pieces  of  tissue  are  used,  in  from  ten  to 
fourteen  days. 

Apparatus  required  in  Staining 

As  regards  apparatus  required,  this  depends  upon  the  way  in 
which  the  sections  have  been  cut.  Slides  3  in.  x  I  in.  for  ordinary 
sections,  and  3  in.  x  i^  in.  for  larger  sections,  as  well  as  cover- 


336  APPENDIX  A 

glasses  (No.  i  and  No.  2)  will  always  be  required.  For  sections 
cut  frozen  or  in  celloidin,  a  series  of  watch-glasses  to  hold  the 
staining  fluids  and  reagents,  a  bowl  of  water  for  washing 
between  the  processes,  needles  for  lifting  the  sections,  drop- 
bottles  containing  absolute  alcohol  and  xylol,  and  a  bottle  of 
Canada  balsam,  also  glycerine  jelly  or  Farrant's  medium,  are 
all  that  is  required.  In  the  case  of  sections  cut  in  paraffin, 
these  may  have  been  mounted  either  upon  cover-glasses  or 
on  slides.  In  the  former  case,  a  series  of  drop-bottles  con- 
taining the  reagents  and  a  pair  of  Cornet's  forceps  to  hold 
the  specimen  are  all  that  is  necessary.  In  the  latter  case  it 
is  well  to  have  a  series  of  stoppered  jars,  of  a  size  suitable 
for  holding  at  least  two  slides,  back  to  back,  for  stains  and 
reagents.  A  tap  for  cold  water  and  a  sink  should  be  at  hand, 
also  a  jar  containing  distilled  water.  A  pair  of  scales  for 
weighing  out  stains  is  also  necessary. 

For  sections  cut  in  celloidin,  watch-glasses  or  other  small 
glass  dishes  for  the  stains  and  reagents,  and  needles  for  lifting 
the  sections,  are  required. 

Slides  and  cover-glasses  should  always  be  clean ;  more 
especially  they  should  be  free  from  grease.  The  best  way  of 
securing  this  is  to  place  them  in  strong  hydrochloric  acid  for 
a  short  time,  then  wash  in  running  water,  and  finally  put  them 
into  a  jar  with  a  properly  fitting  top  containing  methylated 
spirit.  From  this  spirit  they  are  taken  and  dried  with  a  clean 
cloth  as  they  are  required. 

Mounting  Media 

Canada  Balsam. — This  is  prepared  by  dissolving  the  balsam 
either  in  benzol  or  xylol.  The  solvent  is  added  in  sufficient 
quantity  to  give  a  yellow  fluid  with  a  syrupy  consistence.  The 
balsam  should  be  kept  in  one  of  the  specially  prepared  stoppered 
bottles.  It  is  necessary  to  add  a  little  of  the  solvent  from  time 
to  time  to  replace  that  which  evaporates. 

In  the  case  of  tissues  treated  with  osmic  acid,  chloroform 
should  take  the  place  of  the  benzol  or  xylol. 

Sections  which  have  been  stained  in  anilin  dyes  such  as 
thionin  tend  to  become  discolourised  when  mounted  in  ordinary 
balsam.  This  is  due  to  the  fact  that  ordinary  balsam  is  acid 


APPENDIX  A  337 

as  a  result  of  oxidation.  In  neutral  balsam,  which  may  be 
obtained  from  Griibler,  Leipzig,  the  colour  is  preserved  for 
a  much  longer  period.  Another  way  of  getting  over  the 
difficulty  is  to  mount  the  section  in  Colophonium  dissolved  in 
terpentine  oil. 

Glycerine  Jelly. — This  is  specially  useful  in  mounting 
sections  which  have  been  stained  for  fat  or  waxy  material. 
It  contains — 

Gelatine  (Coignet's)        .          .      30  parts. 
Distilled  water       .          .          .      70     ,, 
Glycerine      .          .          4          .100     ,, 
Alcoholic  solution  of  camphor        5      ,, 

After  standing  overnight  in  the  distilled  water  the  gelatine 
and  water  are  boiled  and  subsequently  strained  through  a 
warm  filter.  The  glycerine  and  camphor  are  added  and  mixed 
thoroughly.  Before  use  the  medium  should  be  liquefied  by 
being  placed  in  warm  water. 

Farr ant's  Medium. — Equal  parts  of  water,  glycerine  and 
a  saturated  watery  solution  of  arsenious  acid  (saturated  by 
boiling)  are  mixed  together  thoroughly.  To  this  is  added 
about  half  its  bulk  of  gum-arabic.  The  mixture  is  stirred 
from  time  to  time  until  solution  is  complete.  It  is  then  filtered 
and  a  little  carbolic  (i  :  20)  added. 


STAINING  METHODS 

Treatment  of  Sections  cut  in  Paraffin  before  Staining. — Before 
staining,  sections  which  have  been  cut  in  paraffin  require  to 
be  treated  with  some  solvent  for  paraffin,  such  as  benzol  or 
xylol.  The  reagent  is  dropped  on  to  the  section  and  the  slide 
or  cover-glass  gently  tilted  backwards  and  forwards  for  some 
seconds.  The  benzol  is  then  poured  off  and  replaced  by  fresh. 
The  process  of  solution  of  the  paraffin  may  be  hastened  by 
warming  the  slide  or  cover-glass  very  gently  well  above  the 
flame  of  a  bunsen  until  the  paraffin  is  seen  to  melt.  The 
benzol  is  then  poured  on  and  allowed  to  remain  for  a  few 
seconds. 

The  benzol  must  now  be  washed  off  by  means  of  a  few 
drops  of  methylated  spirit,  the  slide  being  inclined  so  as  to 


338  APPENDIX  A 

allow  the  fluid  to  run  away.  The  section  is  now  gently 
immersed  in  water  and  left  for  a  few  minutes  before  staining. 
The  stain  is  then  dropped  or  filtered  on  to  the  section,  or  the 
section  and  slide  are  placed  in  a  suitable  jar  containing  the 
stain. 

Treatment  of  Sections  cut  in  Celloidin  and  Gum. — Sections 
cut  in  gum  or  in  celloidin  are  taken  direct  from  water  by 
means  of  a  needle  and  placed  in  the  staining  fluid,  usually  in 
a  watch-glass  or  similar  hollow  dish.  Such  sections  stain 
much  more  rapidly  than  those  cut  in  paraffin,  by  reason  of  the 
fact  that  the  stain  acting  upon  the  tissue  from  both  sides 
penetrates  more  readily. 

Picro-Carmine 

This  is  a  combined  nuclear  and  protoplasmic  stain.  It 
also  has  the  advantage  of  differentiating  between  various 
types  of  tissues  and  cells.  The  nuclei  of  cells  and  fibrous 
tissue  are  stained  brilliant  crimson.  Epithelial  cells,  necrotic 
material,  fibrin  and  elastic  tissue  are  stained  yellow.  The 
stain  is  prepared  as  follows  : — 

Pure  carmine  I  part. 

Liq.  ammoniae  fort.  .          .      3  parts. 

Dist.  water      .          .          .  3     „ 

Dissolve  the  stain  in  a  test  tube  in  the  ammonia  and  water 
and  add  200  parts  of  a  cold,  saturated,  and  filtered  solution 
of  picric  acid,  and  mix  thoroughly.  Place  the  fluid  in  a  basin 
covered  with  glass  and  allow  to  ripen  in  direct  sunlight, 
testing  its  powers  of  staining  from  time  to  time.  To  prevent 
the  picric  acid  crystallising  out,  add  10  to  20  per  cent  of 
distilled  water  to  the  fluid  that  remains.  Add  also  2  to  6  drops 
of  i  to  20  carbolic  to  prevent  the  growth  of  fungi. 

Method. 

Spread  the  section  out  on  a  cover-glass,  drain  off  super- 
fluous water.  Run  several  drops  of  staining  fluid  over  and 
allow  to  stand  for  fifteen  to  twenty  minutes.  Drain  off  excess 
of  stain.  Do  not  wash.  Mount  in  Farrant's  medium. 

The  method  is  specially  useful  for  sections  cut  in  gum. 


APPENDIX  A  339 

Haematoxylin  (Hsematein),  Eosin 

Haematoxylin  is  obtained  from  the  wood  of  Hamatoxylon 
catnpechianum  by  extraction  with  ether.  It  is  not  in  itself  a  dye 
but  becomes  one  on  oxidation.  In  its  oxidised  form  it  is  known 
as  haematein.  Neither  the  original  substance  nor  the  oxidation 
product  is  capable  of  staining  directly.  Each  requires  a 
mordant  added  to  it  or  used  separately.  As  mordants,  alum 
and  iron  are  very  commonly  used. 

There  are  many  useful  methods  for  staining  with  haema- 
toxylin  and  haematein.  They  all  give  very  similar  results,  the 
nuclei  staining  a  dark  blue  or  purple  colour. 

Of  the  haematoxylin  methods  probably  the  best,  both  as 
regards  ease  of  preparation  of  the  stain  and  rapidity  of  action, 
is  Weigert's  iron-haematoxylin. 

Weigerfs  Iron-Hcematoxylin. — Two  solutions  are  prepared, 
No.  i  containing  the  haematoxylin,  No.  2  the  mordant  (iron). 
These  solutions  keep  well  separately.  For  use,  equal  parts  of 
the  two  are  mixed  together.  The  mixture  will  stain  at  once, 
but  is  better  after  twenty-four  hours.  It  will  keep  good  for 
eight  to  fourteen  days. 

The  solutions  are  made  up  as  follows  : — 

Solution   i 

Haematoxylin  .          .          .          .      i  grm. 
Alcohol  96  per  cent  »      j  •»-     100  c.c. 

Solution  2 

Liq.  ferri  perchlor.  (S.G.  1-124)  4  c.c. 

Dist.  water       .          .          .          .100  c.c. 
Hydrochloric  acid  (cone.)  .          .  i  c.c. 

The  mixture,  which  has  a  brownish-black  colour,  is  dropped 
on  to  the  section  and  allowed  to  remain  from  one  to  five  minutes. 
Better  results  are  obtained  by  differentiation  for  one  or  two 
seconds  in  acid  alcohol  (i  per  cent  hydrochloric  acid  in 
methylated  spirit).  The  section  is  then  thoroughly  well  washed 
in  tap  water  and  counterstained  with  eosin  or  picro-fuchsin 
(van  Gieson's  stain). 


340  APPENDIX  A 

An  excellent  hasmatein  is  that  recommended  by  Mayer. 
It  is  prepared  as  follows  : — 

Hsematein  i  grm. 

90  per  cent  alcohol          .          .50  c.c. 
Alum    .          .          .          .          -So  grm. 
Water i  litre. 

A  crystal  of  thymol  is  added  to  prevent  the  growth  of 
moulds.  The  haematein  should  be  dissolved  first  in  the 
alcohol  by  the  aid  of  warmth,  and  then  added  to  the  water  in 
which  the  alum  has  been  already  dissolved. 

The  stain  improves  on  keeping.  The  ripening  process  is 
more  rapid  if  the  stain  be  exposed  to  sunlight.  At  first  it  may 
require  half  an  hour  or  even  longer  to  stain  ;  later,  ten  to  fifteen 
minutes  is  sufficient.  If  the  stain  is  too  deep  or  too  diffuse  a 
few  seconds  in  acid  alcohol  (hydrochloric  acid  I  per  cent  in 
methylated  spirit)  will  differentiate.  The  section  is  then  washed 
thoroughly  in  tap  water  until  the  blue  colour  returns. 

Method. 

i.  Stain  in  haematoxylin  for  two  to  five  minutes  or  haematein 
ten  to  thirty  minutes. 

(2.  Differentiate  in  acid  alcohol  if  necessary.) 

3.  Wash  thoroughly  in  water. 

4.  Counterstain  in  \  per  cent 'watery  eosin  for  one  to  four 
minutes. 

5.  Wash  in  water. 

6.  Dehydrate,  and  at  the  same  time  take  out  some  of  the 
eosin  in  absolute  alcohol. 

7.  Clear  in  benzol. 

8.  Mount  in  balsam. 

In  the  case  of  sections  cut  in  gum  or  in  celloidin  a  much 
shorter  period  is  required  for  staining  in  the  haematein  and 
eosin  solutions. 

Hsematoxylin  combined  with  Picro-fuchsin  (van  Gieson's 
stain) 

For  this  combination  the  haematoxylin  or  haematein  may 
be  any  of  those  in  common  use,  such  as  the  above  mentioned, 
but  it  is  necessary  when  using  these  with  picro-fuchsin  to  stain 


APPENDIX  A  341 

for  a  longer  period  than  when  eosin  is  used,  as  the  picric  acid 
tends  to  decolourise  the  haematein.  Another  alternative  is  to 
use  a  stronger  nuclear  stain,  and  for  this  purpose  Weigert's 
iron-haematoxylin  has  no  rival. 

Van  Giesorts  Solution. — It  is  best  to  prepare  a  stock 
solution  as  follows  : — 

Acid  fuchsin         .          ,          .          -1*5  grm. 
Saturated  watery  solution  of  picric 

acid  (about  0-6  per  cent)  .      150  c.c. 

This  solution  keeps  well.  For  use,  mix  i  c.c.  of  the  stock 
solution  with  10  c.c.  saturated  watery  solution  of  picric  acid. 
This  solution  will  also  keep  for  some  weeks. 

Method. 

1.  Stain  in  iron-haematoxylin  for  two  to  five  minutes  or  in 
haematein  for  fifteen  to  thirty  minutes. 

2.  Wash  in  water. 

3.  Stain  in  picro-fuchsin  ten  to  thirty  seconds. 

4.  Wash  rapidly  in  water. 

5.  Dehydrate  rapidly  in  absolute  alcohol. 

6.  Clear  in  carbol-xylol  (or  carbol-benzol). 

The  advantages  of  the  carbol-xylol  is  that  dehydration  need 
not  be  very  complete  if  it  is  used.  This  is  of  importance 
because  prolonged  treatment  in  alcohol  extracts  the  stain. 
The  mixture  consists  of  three  parts  xylol  (or  benzol)  to  one 
of  melted  crystalline  carbolic  acid. 

7.  Clear  again  in  xylol  (in  order  to  get  rid  of  the  carbolic). 

8.  Mount  in  Canada  balsam. 

The  special  advantage  of  the  van  Gieson  method  is  that 
a  differentiation  is  effected  between  certain  types  of  cells  and 
tissues.  Red  blood  corpuscles  are  stained  a  bright  yellow 
colour,  connective  tissue  fibres  red,  and  muscle  fibres  yellow 
or  brownish-yellow. 

In  staining  sections  cut  in  gum  or  in  celloidin  with  picro- 
fuchsin  a  longer  period  of  washing  in  water  is  required. 

Eosin,  Methylene  Blue  Staining  Method 

This  is  a  method  of  very  general  applicability.  In  some 
schools  in  America  it  is  used  as  the  routine  staining  method. 


342  APPENDIX  A 

It  has  many  advantages.  It  is  a  fairly  sharp  nuclear  stain, 
but  its  chief  advantage  is  as  a  stain  for  protoplasm.  The 
structure  of  the  protoplasm,  more  particularly  any  granules 
which  it  may  contain,  are  brought  out  with  the  characteristic 
reaction  to  the  acid  (eosin)  and  basic  (methylene  blue)  dyes. 
The  outline  of  the  individual  cells  will  be  brought  out  very 
clearly  and  their  relative  size  thus  more  easily  estimated. 
Moreover,  any  bacteria  present  will  be  stained  with  the 
methylene  blue. 

In  order  to  get  the  best  results  the  tissue  should  be  fixed  in 
Zenker's  fluid  or  in  saturated  corrosive  sublimate.  Fairly  good 
results  will,  however,  be  obtained  with  formalin-fixed  tissue. 

Method. — A  simple  method  of  using  the  stains  is  as 
follows  : — 

1.  Stain   in   eosin   (i    per   cent   aq.    solution)  five   to   ten 
minutes. 

2.  Wash  in  water. 

3.  Stain  in  methylene  blue  (i   per  cent  aq.  solution)  half 
minute. 

4.  Wash  in  water. 

5.  Differentiate  and  dehydrate  in  absolute  alcohol. 

6.  Clear  in  xylol  or  benzol  and  mount  in  balsam. 

After  staining  with  the  eosin,  Potas.  Alum  (sat.  sol.)  may 
be  used  for  fixing  the  stain. 

The  differentiation  should  be  carefully  carried  out  and 
controlled  by  putting  the  section  under  a  low  power  of  the 
microscope,  and  noting  the  point  at  which  the  nuclei  of  the 
cells  become  sufficiently  clear.  The  method  requires  some 
'practice  before  the  best  results  are  obtained. 

Mallory  and  Wright  recommend  the  following  : — 

1.  Stain  in  eosin  (5  percent  aq.  sol.)  for  twenty  minutes  or 
longer. 

2.  Wash  in  water. 

3.  Stain  in  Unna's  alkaline  methylene  blue  (one  part  in 
five  of  water)  for  ten  to  fifteen  minutes. 

Unna's  Alkaline  Methylene  Blue 

Methylene  blue    .          .          .          .          .      i  grm. 
Carbonate  of  potassium          .          .  i  grm. 

Water  100  c.c. 


APPENDIX  A  343 

4.  Wash  in  water. 

5.  Differentiate  in  alcohol,  clear  and  mount. 

According  to  Mallory  and  Wright  the  success  of  the 
method  depends  upon  the  presence  of  colophonium  in  the 
alcohol  used  for  differentiation.  This  is  usually  present  in 
alcohol,  but  it  may  be  necessary  to  add  it  in  such  quantity 
as  to  make  a  I  o  per  cent  solution. 

A  stain  which  gives  very  similar  results  is  prepared  by 
diluting  Leishman's  stain  with  nine  parts  of  water.  The 
sections  are  allowed  to  remain  in  this  stain  for  twenty-four 
hours.  They  are  then  differentiated  in  a  very  dilute  solution 
of  acetic  acid  (i  :iooo),  washed  in  water,  dehydrated,  cleared 
and  mounted  in  balsam.  This  makes  an  excellent  counterstain 
instead  of  methylene  blue  after  using  Ziehl-Neelsen's  carbol- 
fuchsin  for  staining  tubercle  bacilli. 

Pyronin-Methylgreen  Method  (Unna-Pappenheim) 

This  is  a  useful  method  for  differentiating  the  various 
types  of  cells  in  inflammatory  tissue,  more  especially  for 
demonstrating  "  plasma  cells."  The  staining  mixture 
(pyronin-methylgreen)  is  best  obtained  ready  made  from 
Grubler. 

1.  Fix  in  alcohol,  formalin,  or  Orth's  fixative. 

2.  Stain  in  pyronin-methylgreen  mixture  for  10-15  minutes, 
warming  the  slide  slightly. 

3.  Wash  in  water  for  several  minutes. 

4.  Differentiate  in  70  per  cent  alcohol. 

5.  Dehydrate  rapidly,  clear,  mount. 

By  the  above  method  the  protoplasm  of  the  "  plasma 
cells"  is  deep  red,  the  nucleus  green. 

Elastic  Tissue  Stain 

Elastic  fibres  enter  into  the  formation  of  many  tissues  and 
organs  in  the  body.  More  especially  is  this  the  case  with 
the  lungs  and  testicle  and  with  vessels  (other  than  capillaries) 
and  skin.  In  studying  pathological  changes  in  these  tissues 
it  is  therefore  absolutely  necessary  to  employ  some  method 
for  the  demonstration  of  the  elastic  fibres.  A  number  of 


344  APPENDIX  A 

staining  methods  will  show  elastic  fibres,  but  for  the  study  of 
changes  in  these  fibres  special  selective  methods  must  be 
employed.  Of  these  selective  methods,  undoubtedly  the  best 
is  Weigert's  resorcin-fuchsin  method. 

The  stain  may  be  obtained  in  the  form  of  powder  or  fluid, 
but  it  is  easily  prepared  as  follows  : — 

Resorcin  .  .  .4  grin. 
Fuchsin  (Griibler)  .  .  2  grm. 
Water  .  .  .  200  c.c. 

Bring  the  mixture  to  the  boil  in  a  porcelain  dish,  and  add 
25  c.c.  of  the  liquor  ferri  sesquichloridi  (Pharm.  Germ.  S.G.  i«i). 
Boil  for  five  minutes,  stirring  at  the  same  time.  A  pre- 
cipitate forms  which  after  cooling  is  filtered.  .  This  precipitate 
is  dissolved  in  200  c.c.  of  94  per  cent  alcohol,  heat  being 
applied  till  the  alcohol  boils.  The  solution  is  then  allowed 
to  cool,  made  up  to  200  c.c.  with  alcohol,  and  4  c.c.  of  hydro- 
chloric acid  added. 

Method. 

1.  Tissues    are   fixed    in   formalin   or    corrosive,  hardened 
in  alcohol  and  cut  in  paraffin,  celloidin,  or  better,  in  gum  with 
the  freezing  microtome.      It  is  well  to  cut  the  sections  fairly 
thick  (20-40  /x)  in  order  that  the  sinuosities  of  the  fibres  may 
be  followed.     Tissue  hardened  in  alcohol  must  of  course  be 
washed  thoroughly  in  water  (twenty-four  hours)  before  being 
placed  in  gum. 

2.  Stain  sections  in   lithium   carmine  one  to  five  minutes 
(paraffin  sections  twenty-four  hours). 

Orttts  Lithiitm  Carmine 

Carmine     ......      5  grm. 

Sat.  aq.  sol.  of  lithium  carbonate  .          .      100  c.c. 
Thymol,  a  few  crystals. 

3.  Differentiate  in  acid  alcohol  (p.  339)  for  one  to  twenty-four 
hours.     The  longer  the  sections  are  left  in  this  the  better  the 
result. 

4.  Place  direct  in  resorcin-fuchsin  mixture  for  ten  minutes 
(gum   sections)   to    one   hour    (paraffin    sections).     The    stain 


APPENDIX  A  345 

tends  to  become  less  active  on  keeping,  but  the  differentiation 
is  better. 

5.  Differentiate  and  dehydrate  in  absolute  alcohol.     In  the 
case  of  gum  sections,  this  is.  best  done  in  a  "  Petri  dish "  so 
that  the  section  can  be  spread  out  on  the  slide  while  in  the 
alcohol. 

6.  Clear  in  carbol-xylol  or  carbol-benzol. 

7.  Afterwards  in  xylol  or  benzol  and  mount  in  balsam. 

By  this  method  the  elastic  fibres  are  stained  dark  blue,  the 
cell  nuclei  red.  The  elastic  tissue  stain  can  be  used  along  with 
other  staining  methods.  A  very  good  combination  is  the 
following  : — 

Stain  in  iron-haematoxylin,  then  in  Weigert's  resorcin-fuchsin, 
and  finish  up  with  picro-fuchsin. 

Fibrin  Staining  Method 

Weigert's  fibrin  method  is  merely  a  modification  of  the 
Weigert  -  Gram  method  for  staining  bacteria,  and  sections 
stained  with  it  will  also  show  gram  positive  organisms.  The 
method  is  particularly  adapted  for  demonstrating  the  exudate 
in  acute  inflammations  of  pleura,  pericardium  and  lung,  also 
for  the  fibrin  network  in  thrombi. 

Method. 

1.  Fix  in  formalin  or  corrosive  sublimate,  but  not  in  M  tiller's 
or  Orth's  fluid. 

2.  Cut  in  gum,  paraffin  or  celloidin. 

3.  Stain  in   lithium   carmine  (see  p.  344),   in   the  case  of 
paraffin  sections  for  some  hours,  in  the  case  of  gum  or  celloidin 
sections  for  one  to  five  minutes. 

4.  Differentiate  in  acid  alcohol  for  some  time,  best  twenty- 
four  hours. 

5.  Wash  well  in  water. 

6.  Stain  in  anilin  gentian  violet  (p.  363)  five  to  ten  minutes. 

7.  Pour  off  excess  and  blot  carefully. 

8.  Mordant  in  iodine  solution  for  two  minutes. 

Potassium  iodide         .   .       .          .      5  grm. 

Water 100  c.c. 

Iodine  in  excess. 


34^  APPENDIX  A 

9.  Pour  off  excess  and  blot  firmly. 

10.  Differentiate  in  anilin-xylol  (equal   parts    of  anilin   oil 
and  xylol). 

11.  Clear  in  xylol,  mount. 

By  this  method  the  fibrin  is  stained  blue  while  the  nuclei 
of  cells  are  stained  red. 

Staining  of  Fat  in  the  Tissues1 

Fat  occurs  in  the  tissues  as  (i)  neutral  fats  (combinations 
of  fatty  acid  and  glycerine)  ;  (2)  fatty  acids  (palmitic,  stearic, 
or  oleic) ;  (3)  soaps  (combinations  of  fatty  acids  and  alkalies — 
potassium,  sodium,  or  calcium)  ;  (4)  combinations  of  fat  with 
protein  (albumin  soaps).  All  the  first  three  varieties  are 
demonstrable  by  microchemical  means,  the  last  only  by 
chemical  analysis. 

In  order  to  demonstrate  fat  by  staining  methods  it  is  neces- 
sary to  cut  sections  of  the  tissues  fresh  or,  better,  after  fixation 
with  formalin.  The  portion  of  tissue  is  taken  direct  from  the 
formalin  and  frozen,  or  it  is  placed  for  some  hours  in  gum 
(p.  326)  and  then  cut.  Tissues  passed  through  the  usual  re- 
agents and  cut  in  paraffin  or  celloidin  have  all  their  fat  removed, 
unless  they  have  been  fixed  previously  in  osmic  acid,  which 
stains  certain  fats  black,  or  in  a  chrome  salt  such  as  bichrom- 
ate of  potash. 

Basic  anilin  dyes  will  stain  fats  in  the  form  of  free  fatty 
acid  by  combining  with  them  to  form  coloured  soaps.  As  a 
rule  fatty  acids  occur  in  small  amount  in  the  fat  of  tissues, 
although  in  some  morbid  conditions  (e.g.  fat  necrosis)  they  are 
present  in  large  amount.  The  neutral  fats,  which  are  the  pre- 
dominant form,  are,  however,  readily  hydrolysed  by  the  action 
of  acids  and  so  split  into  fatty  acid  and  glycerine.  The  car- 
bonic acid  of  the  atmosphere  will  act  in  this  way.  This 
hydrolysed  fat  will  take  on  the  basic  anilin  dye.  In  this  way 
the  fat  in  sections  stained  with  such  a  dye  and  exposed  to  the 
air  or  to  the  action  of  an  acid  such  as  sulphurous  acid  gradu- 
ally combines  with  the  dye  and  so  becomes  coloured.  In 

1  Lorrain-Smith  and  Mair,  Journal  of  Pathology  and  Bacteriology, 
1906,  vol.  xi.  p.  415  ;  ibid.,  1908,  vol.  xii.  pp.  i,  126,  134  ;  ibid.t  1908, 
vol.  xiii.  pp.  14,  345;  ibidtt  1911,  vol.  xv.  pp.  53,  180. 


APPENDIX  A  347 

other  words,  globules  of  acid  fat  are  stained  immediately  with 
basic  anilin  dyes,  while  globules  of  neutral  fat  remain  un- 
stained until  they  have  been  hydrolysed  and  the  fat  has 
become  acid. 

Demonstration  of  Fat  by  Haematoxylin.  —  Fat  in  the 
tissues  will  stain  with  hcBmatoxylin^  in  a  similar  way  to  myelin 
in  Weigert's  method,  after  partial  oxidation  by  fixation  in  bi- 
chromate of  potash  or  in  chromic  acid.  The  fat,  however, 
takes  considerably  longer  than  the  myelin  to  reach  the  stage 
of  oxidation  at  which  it  will  "  lake  "  hasmatoxylin. 

In  order  to  stain  sections  of  fatty  liver  in  this  way  the 
piece  of  tissue,  after  rapid  fixation  in  formalin,  should  be  cut 
in  gum  and  the  sections  placed  in  a  saturated  solution  of 
potassium  bichromate  at  37°  C.  for  a  fortnight.  At  the  end 
of  this  time  they  are  stained  in  Kultschitzky's  haematoxylin, 
and  differentiated  as  on  p.  355,  or  by  means  of  Weigert's 
borax-ferricyanide  mixture  prepared  as  follows  : — 

Borax       .          .          .          .          .2  grm. 
Pot.  ferricyanide        ,    :      .          .     2-5  grm. 
Water      .  .          .          .100  c.c. 

Demonstration  of  Fat  by  Osmic  Acid. — For  this  purpose 
osmic  acid  i  per  cent  solution  in  water  or  any  of  the  fixatives 
containing  osmic  acid,  such  as  Flemming's  (p.  328)  or 
Marchi's  (p.  328)  solutions,  may  be  used.  The  action  de- 
pends upon  the  reduction  of  the  osmium  peroxide  to  osmium 
oxide.  Only  certain  fats  are  blackened  in  this  way,  more 
especially  olein  and  oleic  acid.  The  pieces  of  tissue  treated 
should  be  very  thin  as  the  osmic  acid  does  not  penetrate  well. 

One  advantage  of  the  method  is  that  the  tissue  can  after- 
wards be  embedded  in  paraffin  or  celloidin,  although  in  the 
case  of  paraffin  embedding  xylol  should  not  be  used.  Subse- 
quent staining  with  safranin  (i  per  cent)  gives  very  good 
results. 

The  staining  with  osmic  acid  can  also  be  carried  out  with 
sections  cut  in  gum.  The  sections  are  placed  in  ±  per  cent 
solution  of  perosmic  acid  for  12  hours  in  the  dark,  washed 
well  in  water,  and  mounted  in  Farrant's  solution. 

Lorrain-Smith's  Nile  Blue  Sulphate  Method. — Nile  blue 
sulphate  (A)  is  a  dye  of  the  oxazine  series,  and,  like  other  basic 


348  APPENDIX  A 

anilin  dyes,  it  combines  with  fatty  acid  forming  a  coloured 
soap.  When  sections  of  tissue  containing  fat  are  stained  with 
it,  the  larger  proportion  of  the  fat  globules  are  found  stained  a 
brilliant  red,  others  are  stained  a  deep  blue,  while  others  are 
purple.  The  explanation  of  this  is  that  the  dye  in  watery 
solution  contains  a  red  substance  (oxazone  base),  which  is 
derived  from  the  blue  dye  (oxazine  base)  by  a  process  of  oxida- 
tion. This  transformation  can  be  carried  out  more  rapidly 
by  heating  the  blue  stain  for  some  hours  in  the  presence  of 
acid.  This  red  oxazone  base  is  readily  soluble  in  both  fatty 
acids  and  neutral  fats,  and  in  virtue  of  this  leaves  the  stain 
and  concentrates  in  the  fat.  This  solution  of  the  dye  in  the 
fat  is  a  rapid  process.  Hence  the  great  proportion  of  the  fat 
in  the  tissue  will  be  coloured  red.  The  blue  stained  globules 
represent  the  fatty  acid  portion  of  the  fat  which  has  combined 
with  the  basic  dye  (oxazine  base)  to  form  a  soap.  This  pro- 
cess is  a  relatively  slow  one. 

When  both  neutral  fat  and  fatty  acid  are  present  in  a 
globule,  both  stains  act,  thus  giving  a  purple  colour. 

Method. 

1.  Fix  in  formalin. 

2.  Cut  in  gum  with  freezing  microtome. 

3.  Place  the  sections  in  a  concentrated  watery  solution  of 
Nile  blue  sulphate  for  ten  minutes. 

4.  Wash  in  water. 

5.  Differentiate  in  i  per  cent  acetic  acid. 

6.  Wash  thoroughly. 

7.  Mount  in  Farrant  or  in  glycerine  jelly. 

Method  of  staining  Fats  with  Sudan  III.  and  Scharlach 
R. — Sudan  III.  and  Scharlach  R.  are  two  anilin  dyes  belonging 
to  the  azo  group,  closely  allied  to  one  another,  the  latter  being 
richer  by  two  methyl  groups  than  the  former,  and  in  conse- 
quence being  the  stronger  stain.  Both  dyes  are  readily 
soluble  in  alcohol  and  in  fat,  but  not  in  water.  It  is  in  virtue 
of  their  solubility  in  fat  that  the  colouration  takes  place.  Both 
stains  are  capable  of  colouring  all  types  of  fat  —  fatty  acid, 
neutral  fat,  and  soaps.  This  fact,  in  conjunction  with  the  ease 
of  staining,  renders  them  the  best  all-round  dyes  for  fatty 
changes.  Because  of  its  more  intense  staining,  Scharlach  R. 
is  to  be  preferred  to  Sudan  III. 


APPENDIX  A  349 

Method. 

1.  Formalin  fixed  tissue. 

2.  Cut  in  gum  with  freezing  microtome. 

3.  Place  sections  in  70  per  cent  spirit  for  a  few  seconds. 

4.  Then  in  a  saturated  solution  of  Scharlach  R.  in  70  per 
cent  alcohol,  previously  filtered,  for  ten  minutes  to  twenty-four 
hours  in  covered  dish.      (The  longer  the  sections  remain  in  the 
solution,  the  more  intense  is  the  staining.) 

5.  Transfer  to  70  per  cent  spirit. 

6.  Wash  in  water. 

7.  Counterstain  for  five  minutes  in  alum  hasmatein. 

8.  Mount  in  Farrant  or  in  glycerine  jelly. 

Owing  to  the  fact  that  the  stains  are  not  very  soluble  in 
70  per  cent  alcohol,  a  relatively  long  period  is  necessary  for 
perfect  staining.  The  time  can  be  shortened  considerably  by 
using  one  of  Herxheimer's  methods,  of  which  the  following  is 
the  best : — 

70  per  cent  alcohol  .  .  -5°  c-c« 
Pure  acetone  .  .;  .  .  50  c.c. 
Scharlach  R.  .  .  .  »  excess. 

In  the  mixture  of  alcohol  and  acetone  the  Scharlach  R.  is 
much  more  soluble  than  in  the  alcohol  alone.  Hence  two  to 
five  minutes  suffices  for  staining.  Care  should  be  taken  to 
filter  the  stain  before  use  and  to  keep  the  dish  covered  in 
which  the  staining  is  carried  out  as  otherwise  precipitates 
may  occur. 

Demonstration  of  G-lycogen  in  the  Tissues 

Glycogen  is  a  carbohydrate  which  occurs  in  cells,  e.g. 
liver,  muscle,  kidney,  and,  more  rarely,  in  intercellular  sub- 
stance. It  is  readily  soluble  in  water  but  insoluble  in  alcohol, 
therefore  the  tissue  under  examination  must  not  be  treated 
with  water  or  watery  stains.  It  gives  a  dark  brown  colour 
with  iodine.  For  ordinary  purposes  Ehrlich's  method  is 
quite  good. 

Method. 

1.  Place  tissue  at  once  in  absolute  alcohol. 

2.  Embed  in  paraffin. 

3.  Stretch  the  cut  sections  in  50  per  cent  alcohol. 


350  APPENDIX  A 

4.   Place  a  drop  of  the  following  mixture  on  the  slide  : — 

Gum-arabic    .          .          .          .          .100  parts. 
Lugol's  iodine  solution  (see  below)     .          I  part. 

LugoFs  Solution 

Iodine  .  i  grm. 

Pot.  iodide    .  2  grm. 

Water  ....      300  c.c. 

Place  a  cover-glass  on  the  specimen  and  investigate. 
In  order  to  obtain  permanent  preparations,  more  elaborate 
methods,  such  as  Lubarsch's  and  Best's,  must  be  adopted. 

Lubarsch's  Method 

1.  Fix  tissue  in  absolute  alcohol,   embed  in  paraffin,  cut, 
stretching  sections  in  50  per  cent  alcohol. 

2.  Stain  in  Mayer's  alcoholic  carmine  for  several  minutes. 

Carmine          .          .  4  grm. 

Water   .          .          .          .          .15  c.c. 
Hydrochloric  acid  .          .          .30  drops. 

Dissolve  by  boiling,  add  95  c.c.  of  85  per  cent  alcohol ;  filter 
in  warm  condition  and  neutralise  with  ammonia  until  a  perma- 
nent precipitate  forms,  then  filter  in  the  cold., 

3.  Differentiate  in  acid  alcohol  (see  p.  339). 

4.  Wash  in  absolute  alcohol. 

5.  Stain  in  methylanilin  violet    solution  as  for   Weigert's 
fibrin  method  (p.  345),  warming  slightly  for  two  minutes. 

6.  Wash  very  rapidly  in  water. 

7.  Pour  on  Lugol's    solution   (see  above),   and  leave  for 
10  seconds. 

8.  Dry  with  filter  paper. 

9.  Differentiate  in — 

Anilin  oil          ....      2  parts. 
Xylol i  part. 

10.  Clear  in  xylol  and  mount  in  balsam. 


APPENDIX  A  351 

By  this  method  the  glycogen  is  coloured  blue-violet  and  the 
nuclei  of  the  cells  red. 


Best's  Method 

1.  Fix  in  absolute  alcohol,  embed  in  celloidin  and  cut. 

2.  Stain  in  Weigert's  iron-haematoxylin  (p.  339). 

3.  Differentiate  in  acid  alcohol. 

4.  Wash  rapidly  in  water. 

5.  Stain  in  ammonia  carmine  prepared  as  follows  : — 

Carmine   .  .  .  .  .2  grm. 

Pot.  carbonate  .  .  .  .      i     „ 

Pot.  chloride  .  .  .  .      5     „ 

Dist.  water  ,  .  .  .     60  c.c. 

Boil  for  a  few  minutes,  and   after   cooling  add  ammonia 
20  c.c.     For  use  take — 

Carmine  solution     .          .          .20  parts. 
Ammonia       .  .  30     ,, 

Methyl  alcohol        ,          .          .      30     „ 

Stain  in  this  for  5  minutes  to  24  hours. 

6.  Place  in  differentiating  fluid  for  several  minutes   until 
the  section  is  again  blue.      Differentiating  fluid — 

Abs.  alcohol  .         .          .          .     40  parts. 
Methyl  alcohol        .          .          .      20     „ 
Dist.  water     .          .          .  50     ,, 

7.  Wash  in  80  per  cent  alcohol. 

8.  Dehydrate  in  alcohol,  clear  in  xylol,  mount  in  balsam. 
In  the  above  method  the  hasmatoxylin  may  of  course  be 

omitted.  Paraffin  sections  may  be  treated  similarly  if,  after 
dissolving  out  the  paraffin  with  xylol  and  washing  off  the 
xylol  with  alcohol,  the  sections  are  placed  in  thin  celloidin  for 
3  to  4  hours.  At  the  end  of  that  time  they  are  placed  upon  a 
slide  and  stained  in  Best's  carmine.  The  glycogen  by  this 
method  is  stained  red. 


352  APPENDIX  A 


Demonstration  of  Calcareous  Material  in  the  Tissues 

Haematoxylin  and  hsematein  stain  calcareous  material 
dark  blue. 

Von  Kossa's  Silver  Method. 

1.  Fix  in  formalin  for  a  short  period,  and  cut  with  freezing 
microtome. 

2.  Lay  the  sections  in   5   per  cent  silver  nitrate  in  the  light 
for  10  minutes  to  I  hour. 

3.  Wash  in  distilled  water. 

4.  Transfer    to   a   5    per  cent    solution    of   sodium    hypo- 
sulphite in  order  to  remove  excess  of  silver  nitrate. 

5.  Wash  thoroughly  in  water. 

6.  As  a  counterstain  safranin  (i  per  cent  watery  solution) 
may  be  used. 

7.  Dehydrate,  clear,  mount. 

In  carrying  out  the  above  method  phosphate  of  silver  is 
formed  by  interaction  between  the  silver  nitrate  and  the 
phosphates  of  calcium  and  magnesium.  Under  the  influence 
of  light  the  silver  salt  is  reduced  to  metallic  silver  which 
appears  in  the  section  black. 

Stains  for  Amyloid  or  Waxy  Substance 

Amyloid  or  waxy  degeneration  is  a  change  which  affects 
connective  tissue,  chiefly  that  in  relation  to  blood-vessels. 

The  tissue  becomes  swollen,  transparent,  and  homogeneous. 
The  material  of  which  this  degenerated  tissue  is  composed  is 
an  albuminous  body  combined  with  chondroitin  sulphuric  acid. 

Tissues  containing  waxy  substance  should  be  fixed  in 
formalin  and  hardened  in  spirit,  but  should  not  be  kept  too 
long  in  either  fluid,  as  the  amyloid  material  tends  to  lose  its 
characteristic  staining  properties  in  these  fluids.  It  is  possible, 
however,  to  stain  sections  successfully  which  have  been  kept 
for  years  in  spirit. 

Sections  are  best  cut  in  gum  after  the  spirit  has  been 
thoroughly  washed  out  with  water.  The  waxy  material  is  well 
demonstrated  by  such  ordinary  methods  as  haematoxylin  and 
picro-fuchsin,  by  which  means  it  is  stained  a  yellow-brown 


APPENDIX  A  353 

colour.     There  are  two  selective  methods  for  waxy  material 
— (a)  iodine,  (b]  anilin  stains. 

(a)  Iodine  Method. — The  sections  cut  in  gum  are  placed 
in  an  iodine  solution — Gram's  or  Weigert's  (p.  363)  solutions 
are  both  suitable  —  and    left    there  for  two  to  five  minutes. 
They  are  then  mounted  in  glycerine  jelly  without  washing. 

By  this  means  the  waxy  material  appears,  by  trans- 
mitted light,  a  golden  yellow,  by  reflected  light  a  mahogany 
brown. 

(b)  Anilin  Stains. — A  number  of  anilin  dyes,  which  are 
mixtures  of  several  different  chemical  compounds,  such  as  methyl 
violet  (a  mixture  of  tretra,  penta,  and  hexamethyl-rosanilin), 
gentian  violet  (a  mixture  of  the  chloride  of  penta  and  hexa- 
methyl-pararosanilin),  polychrome  methylene  blue  (formed  by 
boiling  methylene  blue  with  an  alkali  and  containing  methylene 
violet),    show   characteristic   staining   with    tissues   containing 
waxy  material.      In  other  words,  such  tissues  when  stained  by 
one  of  these  dyes  show  the  waxy  material  a  pink  or  purple 
colour  while  the  rest  of  the  tissue  is  stained  blue.      Methyl 
violet  is  probably  the  best-known  stain. 

Method — 

1.  Stain  sections  in  a  i  per  cent  solution  of  methyl  violet 
in  water  for  several  minutes. 

2.  Differentiate  in  acetic  acid,  i  per  cent  in  water. 

3.  Wash  thoroughly  in  water.      Best  for  twenty-four  hours 
in  several  changes. 

4.  Mount  in  glycerine  jelly  or  a  watery  solution  of  levulose. 

Demonstration  of  Iron-containing  Pigment  in  the  Tissues 

The  sections  may  be  fixed  in  formalin  and  cut  in  paraffin 
or  in  gum.     The  latter  is  best  for  the  purpose. 
Method— 

1.  Lay  the   sections   in   a   2   per   cent  watery  solution   of 
ferrocyanide  of  potassium  for  a  few  minutes. 

2.  Transfer    to    hydrochloric    acid    i    per   cent    in    water 
(acid  alcohol  may  be  used),  and  leave*for  one  to  two  hours. 

3.  Wash  in  water. 

The  sections  may  be  counterstained  in  eosin  or,  better,  in 
alum  carmine  prepared  as  follows  : — 

23 


354  APPENDIX  A 

Carmine  .  .  .2  grm. 
Alum  ....  5  grrn. 
Water  .  .  .  .100  c.c. 

Boil  for  one  hour,  allow  to  cool,  and  filter. 
Sections  should  be  stained  for  ten  minutes  (gum  or  celloidin 
sections)  to  twenty-four  hours  (paraffin  sections). 

Demonstration  of  Chromaffin  Cells 

In  cases  which  had  symptoms  suggestive  of  Addison's 
disease  during  life  it  is  necessary  (p.  114)  to  investigate  the 
chromafrln  tissue  of  the  body.  Chromafrin  cells  (cells,  i.e., 
which  have  an  affinity  for  chrome  salts)  are  found  in  the 
medullary  portion  of  the  suprarenals,  in  the  carotid  body,  etc. 
For  the  demonstration  of  such  cells  the  tissues  should  be 
fixed  in  Miiller's  or  Orth's  fluids,  cut  in  gum,  and  stained  in 
some  nuclear  stain,  e.g.  polychrome  methylene  blue,  to  bring 
out  the  nuclei  of  the  cells.  After  such  treatment  the  chromaffin 
cells  assume  a  grass-green  colour. 

Weigert's  Method  for  staining  the  Medullary  Sheath 
of  Nerves 

Methods  for  staining  the  medullary  sheath  of  nerves  are 
all  founded  upon  Weigert's  method,  which  consists  in  fixing 
the  tissue  in  potassium  bichromate,  fluor  chrome,  or  some  such 
mordant,  subsequently  staining  in  hasmatoxylin  and  differen- 
tiating. Under  the  action  of  the  bichromate,  the  myelin 
substance  of  the  medullary  sheath  becomes  partially  oxidised. 
Lorrain  Smith  and  Mair l  bring  forward  evidence  to  show  that 
it  is  probably  cholesterin  in  the  form  of  a  loose  combination 
with  a  fatty  acid  which  becomes  oxidised  during  bichromating. 
The  oxidation,  if  not  too  prolonged,  is  only  partial.  There 
is  still  an  unsaturated  grouping.  On  treatment  with 
haematoxylin  further  oxidation  occurs.  The  oxide  of  chromium 
present  in  the  myelin  combines  with  the  haematoxylin,  so  that 
"laking"  of  the  haemajpxylin,  and  therefore  staining  of  the 
myelin  sheath  takes  place.  It  is  possible  to  prolong  the  treat- 
ment with  the  bichromate  to  such  an  extent  that  there  is 

1  Journal  of  Pathology  and  Bacteriology,  1909,  vol.  xiii.  p.  14. 


APPENDIX  A  355 

complete  oxidation  of  the  myelin  substance,  when  no  staining 
occurs  on  placing  the  tissue  in  haematoxylin. 

By  this  method  the  myelin  sheath  is  stained  a  dark  blue- 
black.  Any  area  of  brain,  cord,  or  nerve,  where  the  myelin 
substance  has  disappeared,  will  remain  unstained.  The 
method  is  adapted  for  demonstrating  such  degenerated  areas. 
They  may  be  brought  into  greater  prominence  by  counter- 
staining  in  picro-fuchsin  (van  Gieson's  stain)  when  the 
degenerated  area  appears  bright  red. 

The  tissue  having  been  mordanted  in  potassium  bichromate, 
e.g.  in  Miiller's  fluid  (see  p.  327),  for  some  six  weeks,  hardened 
in  alcohol,  embedded  in  celloidin,  and  cut,  sections  are  placed 
in  some  preparation  of  haematoxylin,  of  which  one  of  the  best 
is  Kultschitzky  and  Welter's,  prepared  as  follows  : — 

Hasmatoxylin  i  grm. 

Absolute  alcohol         .         .          .10  c.c. 
Acetic  acid  (2  per  cent)       .          .      90  c.c. 

This  solution  should  be  prepared  at  least  a  week  previous  to 
using.      It  keeps  well,  and  indeed  improves  on  keeping. 
Method — 

1.  Stain  in  haematoxylin  twelve  hours  at  37°  C. 

2.  Wash  in  water. 

3.  Place    in    ^    per    cent    watery    solution    of    potassium 
permanganate  for  twenty  to  thirty  seconds. 

4.  Wash  in  water. 

5.  Differentiate    in    equal    parts    of   sulphurous    acid    and 
water  for  a  few  minutes,  i.e.  until  the  grey  matter  is  colourless. 

6.  Wash  thoroughly  in  water. 

7.  If  desired,  counterstain  in  picro-fuchsin  (p.  341). 

8.  Wash  in  methylated  spirit. 

9.  Dehydrate  in  absolute  alcohol. 

10.  Clear  in  benzol. 

1 1.  Mount  in  balsam. 

After  washing  with  water  (2)  and  (6),  it  is  advisable  to 
leave  the  sections  for  some  time  (one  to  two  hours)  in  water  to 
which  a  small  quantity  of  a  solution  of  lithium  carbonate  has 
been  added. 


356  APPENDIX  A 

Marchi's  Method  for  demonstrating  Degenerated  Myelin 

In  areas  of  degeneration  in  brain,  cord,  or  nerve,  as  the 
result  of  disintegration  of  the  myelin  sheath,  globules  of  fatty 
substance  are  set  free.  These  fatty  globules  will  blacken  on 
treatment  with  perosmic  acid,  because  the  fatty  substances, 
having  an  unsaturated  grouping,  are  oxidised  at  the  expense  of 
the  perosmic  acid,  which  is  reduced  to  black  oxide  of  osmium. 
The  normal  myelin  substance  of  nerve  tissue  will  act  in  the 
same  way  if  sections  are  placed  in  perosmic  acid,  directly  or 
after  fixation  in  formalin.  On  the  other  hand,  if  the  nerve 
tissue  containing  the  degenerated  focus  be  exposed  for  a  short 
time  to  the  action  of  bichromate,  the  normal  myelin  sheath 
will  not  blacken,  because  oxidation  of  the  myelin  substance 
occurs.  The  globules  of  fat  in  the  degenerated  area  are  only 
slowly  oxidised  by  the  bichromate,  thus  reduction  of  perosmic 
acid  and  blackening  of  the  globules  results.  As  stated  else- 
where (p.  347),  only  the  olein  compounds  react  in  this  way. 

In  order  to  demonstrate  degenerating  myelin  in  this  way 
a  portion  of  spinal  cord,  brain,  or  nerve  is  placed  in  formalin 
for  twenty-four  hours.  At  the  end  of  that  time  very  thin 
portions  are  removed  from  the  larger  piece  and  placed  in 
Marchi's  fluid  (see  p.  328)  for  three  days.  They  are  then 
washed  thoroughly  in  running  water  and  cut  in  celloidin.  In 
order  to  show  the  nuclei  of  the  cells  safranin  (i  per  cent)  may 
be  used. 

Method  of  demonstrating  Ganglion  Cells  and  their 
Nissl  Bodies 

For  fixation,  any  of  the  fixatives  may  be  used.  Nissl 
recommends  absolute  alcohol.  Small  portions  only  of  the 
tissue  (brain  or  cord)  should  be  taken.  Fixation  and  hardening 
is  complete  in  the  alcohol  in  two  to  three  days.  Nissl  cuts 
the  tissue  embedded  in  gum  arabic  hardened  by  alcohol,  but 
embedding  in  celloidin  or  paraffin  gives  quite  good  results. 

Method — 

1.  Stain   sections   in   Unna's   polychrome   methylene   blue 
(Grubler)  for  ten  minutes. 

2.  Wash  in  distilled  water  for  some  minutes. 


APPENDIX  A  357 

3.  Rinse  in  methylated  spirit,  and  then  in 

4.  Absolute  alcohol  to  which  one  or  two  drops  of  acetic 
acid  have  been  added,  and  afterwards  in  pure  abs.  ale. 

Differentiation  may  also  be  carried  out  in  Unna's  glycerin- 
ether  mixture  (Griibler's)  diluted  with  water. 

5.  Clear. 

6.  Mount.    (Colophonium  dissolved  in  xylol  is  recommended 
for  this  purpose.) 

Instead  of  the  polychrome  methylene  blue,  thionin  or  toluidin 
blue  may  be  used. 

MAKING  OF  BLOOD  FILMS 

(a)  Take  some  perfectly  clean  slides.  Knock  off  the  corner 
of  one  of  them  (so  that  the  end  measures  a  little  less  than  one 
inch)  by  making  a  small  scratch  with  a  glass  cutter.  Place 
a  small  drop  of  blood  at  the  end  of  another  slide  and  with  the 
broken  end  of  the  first  guide  the  drop  along  the  surface.  In 
this  way  a  thin  film  of  blood  will  be  obtained  which  reaches 
not  quite  to  the  margins  of  the  slide  on  either  side. 

(b}  Take  a  number  of  perfectly  clean  square  No.  2  cover- 
glasses.  Place  them  on  filter  paper.  Lift  one  of  them  with 
a  pair  of  small  forceps  and  remove  from  the  pricked  finger 
or  ear  a  very  small  drop  of  blood.  (The  size  of  the  drop 
required  depends  upon  the  size  of  the  cover-glass  ;  only  ex- 
perience will  teach  the  operator.)  Allow  this  cover-glass  to 
rest  upon  another,  the  drop  of  blood  being  between  and  the 
angles  of  the  slips  not  coinciding.  The  weight  of  the  upper 
cover-glass  will  spread  the  blood,  and  if  both  slips  be  clean  an 
eveTi  film  will  be  obtained.  The  lower  cover-glass  is  then  lifted 
by  means  of  the  forceps  by  one  of  the  projecting  angles  and 
grasped  between  finger  and  thumb  by  two  opposite  angles. 
The  upper  cover-glass  is  then  grasped  at  a  projecting  angle  by 
the  forceps  and  gently  slid  off  the  lower. 

Each  film  is  then  allowed  to  dry  in  the  air.  The  forceps 
used  should  be  preferably  non-serrated  at  the  points. 

Staining  of  Blood  Films. — For  ordinary  purposes  this  is 
best  done  by  Jenner's,  Leishman's,  or  Wright's  stains.  In 
each  case  the  stain  is  an  eosinated  methylene  blue  dissolved  in 
pure  methylic  alcohol.  The  stains  may  be  bought  ready  made 


358  APPENDIX  A 

up,  or  tabloids  prepared  by  Burroughs,  Wellcome,  &  Co.  may 
be  used.  These  should  be  dissolved  in  10  c.c.  of  methylic 
alcohol.  No  preliminary  fixation  is  required  as  the  methylic 
alcohol  acts  as  a  fixative.  The  action  of  the  stain  can  be  limited 
by  drawing  two  lines  across  the  slide  with  a  grease  pencil. 

Leishmarfs  and  Wright's  Stains — 

i.  The  stain  is  poured  on  to  the  film  and  allowed  to  remain 
for  one  to  two  minutes. 

2.  Add  an  equal  quantity  (circa]  of  distilled  water  by  means 
of  a  glass  pipette.  Mix  by  gently  rocking,  and  leave  for  three 
to  five  minutes. 

3.  Pour  off  the  stain  and  add  from  time  to  time  distilled 
water,  rocking  the  specimen  to  and  fro  until  the  thinner  portions 
become  pink. 

4.  Pour  off  the  water  and  allow  the  film  to  dry  in  the  air. 
These  stains  are  also  excellent  for  demonstrating  parasites, 

such  as  malaria,  trypanosomes,  etc. 
Jennets  Stain — 

1.  Pour  on  stain  and  leave  for  two  to  four  minutes. 

2.  Wash  off  with  distilled  water,  controlling  the  differentia- 
tion by  examining  under  the  microscope. 

3.  Dry  in  the  air,  placing  in  a  sloping  position. 


BACTERIOLOGICAL  METHODS  OF  INVESTIGATION 

Requisites 

A  bunsen  burner  or,  in  the  absence  of  gas,  a  spirit  lamp 
should  be  close  at  hand.  A  number  of  sterile  pipettes  made 
by  drawing  out  suitable  glass  tubing  in  a  blow  pipe,  and  rubber 
teats  ;  a  looped  platinum  needle  ;  a  flat  piece  of  metal  for 
searing  organs  ;  a  rack  with  culture  tubes  (broth  and  agar  and 
blood-agar  slopes),  and  a  number  of  clean  slides  should  be 
within  reach.  When  culture  tubes  are  not  available,  several 
sterile  test-tubes,  or,  better,  sterile  swabs  in  test-tubes  for 
removing  samples  of  exudate,  will  serve  the  purpose.  In  his 
laboratory  the  pathologist  should,  of  course,  have  an  incubator, 
dyes  for  staining,  etc.,  etc.  A  pencil  for  writing  on  glass  will 
be  found  useful. 


APPENDIX  A  359 


Method  of  inoculating  Culture  Tubes 

Sterilise  the  platinum  needle  by  holding  it  obliquely  in  the 
flame.  Turn  round  the  cotton  wool  plug  of  the  culture  tube 
to  be  inoculated  so  as  to  ensure  its  easy  removal.  Holding 
the  platinum  needle  in  the  right  hand  like  a  pen  and  the 
culture  tube  in  the  left,  remove  some  of  the  exudate  or  pus,  an 
assistant  holding  open  with  forceps  the  incision  previously 
made  into  the  serous  sac,  abscess,  or  organ.  Grasp  the  cotton 
wool  plug  between  the  right  ring  and  little  fingers  and  remove 
it.  Smear  the  surface  of  the  agar  tube  with  the  exudate.  In 
the  case  of  the  broth  tube,  rub  the  loop  of  the  needle  against 
the  side  of  the  tube  at  the  upper  level  of  the  fluid. 

Owing  to  the  fact  that  bacteria  of  all  kinds  rapidly  invade 
the  body  after  death,  chiefly  from  the  alimentary  canal,  bac- 
teriological investigations  carried  out  upon  the  cadaver  are 
not  nearly  so  reliable  as  those  performed  during  the  life  of  the 
patient.  Pathogenic  microbes  tend  to  die  out  and  their  place 
to  be  taken  by  the  unimportant  saprophytic  forms  which  have 
invaded  the  tissues.  At  the  same  time,  where  cultural  investi- 
gations have  not  been  made  during  life,  or  where  the  affected 
focus  is  in  a  part  of  the  body  which  ordinary  clinical  methods 
could  not  reach,  it  becomes  necessary  for  the  pathologist  to 
elucidate  as  far  as  he  can  the  bacteriological  aspect  of  the 
diseased  condition.  Although,  as  we  have  seen,  it  is  advisable 
to  carry  out  the  examination  as  soon  as  possible  after  the  death 
of  the  patient  for  ordinary  purposes,  it  is  doubly  so  when  the 
pathologist  has  in  view  any  bacteriological  investigation.  The 
bacteria  which  invade  the  tissues  multiply  and  spread  at  such 
a  rapid  rate  that  ultimately  any  exact  bacteriological  observa- 
tions become  impossible. 

• 
Examination  of  the  Blood 

This  is,  of  course,  best  done  during  the  life  of  the  patient 
by  drawing  off  1-5  c.c.  of  blood  from  one  of  the  arm  veins. 
In  cases  of  bacteriaemia,  when  this  has  been  omitted  during 
life,  it  is  still  possible  to  carry  out  the  observation  after  death. 
Unfortunately  the  blood  is  the  tissue  of  the  body  most  rapidly 


360  APPENDIX  A 

invaded  by  the  saprophytic  germs.  Nevertheless,  when  care- 
fully done,  the  investigation  is  undoubtedly  useful. 

It  has  been  shown  by  Canon  1  that  it  is  the  blood  in  the 
peripheral  veins  which  gives  the  most  reliable  results,  much 
more  reliable  than  in  the  case  of  the  heart. 

A  large  vein  in  the  arm  should  be  exposed  by  cutting 
through  the  skin,  incised  with  a  sterile  knife,  and  by  pressing 
down  from  above,  a  fair  amount  of  blood  or  blood  serum  can 
be  collected  in  a  syringe  or  pipette.  The  fluid  is  then  added 
to  one  or  more  broth  tubes,  or  smeared  over  an  agar  slope, 
and  incubated. 

The  blood  may  also  be  obtained  from  the  heart  or  from 
the  interior  of  one  of  the  solid  organs,  such  as  the  spleen,  as 
will  be  detailed  later. 

Examination  of  the  Solid  Organs 

The  spleen  in  typhoid  fever,  the  lung  in  pneumonia,  the 
liver  in  cases  of  abscess  formation,  the  brain  in  meningitis  may 
be  examined  in  this  way. 

The  surface  of  the  organ  is  seared  by  means  of  a  red-hot 
flat  piece  of  metal.  A  useful  instrument  for  this  purpose  is  a 
copper  section  lifter.  A  knife  is  sterilised  either  in  the  flame 
or  by  boiling,  and  a  cut  is  made  into  the  substance  of  the 
organ  through  the  seared  portion  of  the  surface.  A  platinum 
loop  is  then  inserted  through  the  opening,  pushed  further  in  if 
that  is  possible,  withdrawn,  and  then  smeared  over  the  surface 
of  an  agar  slope  or  shaken  in  a  broth  tube. 

Smears  on  slides  may  also  be  made  from  the  solid  organs, 
more  especially  spleen  or  lung,  and  stained  to  demonstrate 
bacteria. 

Examination  of  Contents  of  Hollow  Viscera 

Bacteriological  examination  of  the  intestinal  canal  is  seldom 
of  much  use,  owing  to  the  multiplication  of  the  organisms  of 
putrefaction.  In  certain  cases,  however,  useful  information  may 
be  obtained.  In  typhoid  fever,  for  example,  pure  cultures  of 
the  bacillus  typhosus  may  be  obtained  from  the  upper  part  of  the 

1  Die  Bakteriologie  des  Blutes  bei  Infektionskrankheiten,  Jena,  1905. 


APPENDIX  A  361 

jejunum  as  well  as  from  the  urinary  bladder  and  gall  bladder. 
In  opening  these  viscera  for  such  a  purpose,  it  is  well  to  sear 
the  surface,  incise  with  a  sterile  knife,  and  remove  a  sample  of 
the  contents  with  platinum  loop  or  pipette. 


Examination  of  the  Contents  of  Serous  Sacs 

This  is  usually  the  first  and  the  commonest  bacteriological 
problem  which  the  pathologist  encounters.  Where  the  presence 
of  pus  is  suspected  in  one  of  the  serous  sacs,  it  is  necessary  to 
open  the  sac  with  certain  precautions. 

Having  dissected  down  to  the  lining  membrane — pleura, 
pericardium,  peritoneum,  as  the  case  may  be — a  clean  knife 
(bistoury)  and  pair  of  dissecting  forceps  are  taken,  the 
membrane  is  raised  with  the  forceps  and  a  small  incision 
made.  Through  this  a  sterile  platinum  loop  or  a  pipette  is 
inserted,  a  small  quantity  of  the  fluid  removed  and  inoculated 
into  a  series  of  culture  tubes. 

As  a  rule,  the  media  employed  will  be  broth  or  agar  slope, 
and  where  the  presence  of  one  of  the  more  delicate  germs  is 
suspected,  such  as  the  streptococcus,  pneumococcus,  or  influenza 
bacillus,  blood  agar  or  blood  serum.  Subsequently,  a  number 
of  films  from  the  fluid  should  be  made  and  stained. 

Where  the  cavity  has  been  already  opened  into,  that  is, 
before  its  infected  nature  was  realised,  pressure  should  be  exerted 
upon  the  deeper  parts  so  that  some  fresh  fluid  appears,  and  as 
this  flows  over  the  edge  of  the  opening  a  sample  for  inocula- 
tion may  be  obtained  by  means  of  a  platinum  loop  or  pipette. 

Blood  agar  culture  media  may  be  readily  obtained  from 
ordinary  agar  slopes  by  smearing  with  a  platinum  loop  a  little 
blood  from  the  finger  over  the  surface.  The  finger  should  be 
first  rubbed  at  the  root  of  the  nail  with  a  little  methylated  spirit 
which  is  allowed  to  dry.  A  sharp  stab  is  then  made  by  means 
of  a  sharp -pointed  knife  similarly  sterilised,  a  cloth  being 
wrapped  round  the  finger  to  congest  it. 

Method  of  making  Films  from  Pus  and  Sputum 

When  the  pus  or  sputum  is  thick,  an  excellent  method  is 
to  place  a  drop  of  the  fluid  on  a  clean  slide,  place  another 


362  APPENDIX  A 

on  the  top  until  the  pus  has  spread  between  the  two,  then  slide 
them  rapidly  apart.  In  this  way  two  good  films  are  obtained. 
Another  method  is  to  spread  the  fluid  with  the  platinum  needle 
laid  flat  on  the  glass. 

The  film  is  then  dried  by  moving  it  to  and  fro  well  above 
the  bunsen  flame,  and  ultimately  fixed  by  passing  it  thrice 
through  the  flame.  Another  method  of  fixation  is  by  means  of 
absolute  alcohol.  The  alcohol  is  dropped  on  and  left  for  some 
minutes,  after  which  it  is  washed  off  in  water.  Still  another 
fixative  for  films  is  the  following  mixture  : — 

Methylated  spirit .          .          .9  parts. 
Formaldehyde       .          .  i  part. 

This  is  dropped  on  and  left  for  thirty  seconds  to  a  minute,  and 
then  washed  off  with  water. 


Staining  Methods  for  Bacteria 

Bacteria  are  composed  to  a  large  extent  of  nuclear  material. 
Thus  when  it  is  desired  to  demonstrate  them  microscopically, 
they  are  stained  with  nuclear  dyes.  Hasmatoxylin  and  similar 
dyes,  however,  only  stain  organisms  faintly.  It  is  the  basic 
anilin  dyes  which  are  most  commonly  used  for  this  purpose, 
such  as  methylene  blue,  gentian  violet,  basic  fuchsin. 

As  a  rule,  bacteria  do  not  take  up  these  dyes  nearly  so 
readily  as  the  nuclei  of  cells.  In  consequence,  it  is  necessary 
to  enforce  their  action  by  (a)  allowing  the  stain  to  act  for  a 
prolonged  period,  (b)  by  heating,  or  (c)  by  the  addition  of 
some  mordant  to  the  stain,  such  as  carbolic  acid,  caustic 
potash,  anilin  oil.  Once  stained,  however,  the  bacteria  retain 
the  dye  with  much  more  persistence  than  the  nuclei  of  cells 
amongst  which  they  may  lie.  Hence  it  is  possible  by  the  use 
of  a  decolourising  or  differentiating  agent,  such  as  alcohol  or 
some  dilute  acid,  to  bring  the  bacteria  into  greater  prominence 
and  differentiate  them  from  the  surrounding  cells.  This 
resistance  to  decolourising  agents  is  more  marked  in  a  group 
of  bacteria  which  includes  the  tubercle  bacillus.  In  con- 
sequence, the  term  "acid-fast"  is  applied  to  them.  The 
tubercle  bacillus,  after  having  been  stained,  resists  also  the 
decolourising  action  of  alcohol  as  well  as  of  acid. 


APPENDIX  A  363 

Gram's  Method  and  Weigert's  Modification 

1.  Fix  film. 

2.  Filter   on  to   film   or   section   anilin   or   carbol- gentian 
violet  made  up  as  follows  : — 

Saturated  solution  of  anilin  oil  in  water  or 

carbolic  acid  i  to  40  .  .  .  .9  parts. 

Saturated  alcoholic  solution  of  methyl  or  gentian 

violet  .......  i  part. 

For  films  of  bacteria  or  pus  this  should  be  left  on  for  two 
minutes. 

For  sections  of  tissue  it  should  remain  five  minutes. 

3.  Wash  in  water. 

4.  Pour    on    Gram's   or    Weigert's    iodine    solution.     The 
latter  is  three  times  the  strength  of  the  former  and  is  better  for 
this  reason.      It  is  prepared  as  follows  : — 

Iodine  .....  excess. 
Potassium  iodide  .  .  .5  grm. 
Water  .  .  .  .  .  100  c.c. 

The  iodine  is  left  on  for  one  minute  in  the  case  of  films, 
for  two  minutes  in  the  case  of  sections. 

5.  Differentiate  in  methylated  spirit. 

Some  experience  is  required  before  this  can  be  done  suc- 
cessfully. A  few  seconds  is  usually  all  that  is  required  for 
films.  In  the  case  of  sections,  not  quite  all  the  blue  should  be 
removed. 

A  better  method  with  sections  is  to  blot  the  section  firmly 
but  carefully  with  filter  paper  after  the  iodine.  Then  drop  on 
anilin  xylol  (equal  parts  of  anilin  oil  and  xylol).  This  may 
be  allowed  to  act  until  all  the  blue  has  been  removed.  Rapidly 
treat  with  spirit  to  remove  the  anilin  xylol. 

6.  Wash  in  water. 

7.  Counterstain  for  half  a  minute  in  some  red  or  brown 
stain,   such  as  fuchsin,   safranin,  Bismarck  brown,  or  lithium 
carmine  considerably  diluted. 

8.  Wash  in  water. 

9.  In  the  case  of  films,  dry  them  well  above  the  flame.      In 


364  APPENDIX  A 

the  case  of  sections,  dehydrate,  clear,  and  mount  in  Canada 
balsam. 

Carbol- Thionin  Blue 

1.  Filter    on    staining    solution    consisting    of    i    gramme 
thionin   blue  dissolved  in    100  c.c.  carbolic  (i   to   40).     The 
author  has  found  this  stronger  solution  preferable  to  the  dilu- 
tion of  the  above,  in  the  proportion  of  i   of  the  stain  to  3  of 
water,  recommended  by  Muir  and  Ritchie. 

Films  should  be  stained  for  three  to  five  minutes,  sections 
from  five  to  ten  minutes. 

2.  Wash  in  water. 

In  the  case  of  films,  blot,  dry,  and,  if  necessary,  mount. 
In  the  case  of  sections  and  thick  films  of  pus 

3.  Decolourise   very   rapidly  in  i   per  cent  acetic  acid  in 
water. 

4.  Wash  in  water. 

5.  Dehydrate,  clear,  and  mount. 

The  above  is  an  excellent  method  for  demonstrating  the 
ordinary  bacteria  in  films  from  cultures,  in  pus  and  in  tissues. 
It  is  specially  suitable  for  showing  up  masses  of  typhoid 
bacilli  in  spleen  and  mesenteric  glands,  bacillus  coli  in  liver, 
bacillus  pestis  in  spleen  or  bubo,  entamoeba  hystolytica  in 
dysentery,  etc.  The  organisms  stain  a  deeper  purple  than  the 
nuclei  of  the  cells.  Red  blood  corpuscles  in  properly  stained 
specimens  are  yellow. 

Where  the  organisms  are  too  readily  decolourised,  as  in  the 
case  of  bacillus  pestis  sometimes,  after  staining,  instead  of 
washing  in  water  and  decolourising,  blot  the  specimen  and  pour 
on  some  anilin  oil  and  rock  the  slide  to  and  fro  until  the 
greater  portion  of  the  stain  has  come  out,  then  use  xylol  and 
mount  in  balsam. 

This  staining  method  may  also  be  used  for  demonstrating 
mucus  which  takes  on  a  red  or  purple  colour  with  Thionin 
blue. 

Eosin  Methylene  Blue 

This  method  is  given  above  (p.  342).  It  is  well  adapted 
for  demonstrating  masses  of  cocci  in  vegetations,  diphtheria 


APPENDIX  A  365 

bacilli  in  false  membrane,  abscesses,  etc.,  also  entamcebae  in  the 
large  bowel  or  liver. 

Both  this  method  and  the  previous  one  have  this  advantage 
over  Gram's  method  that  the  cells  and  intercellular  fibres  of 
the  tissues  and  bacteria  are  stained  more  naturally.  In  Gram's 
method  the  organisms  appear  often  abnormally  large,  and  the 
tissues  tend  to  be  altered  by  the  iodine. 


Staining  Methods  for  the  Tubercle  Bacillus 

A.  Ziehl-Neelsen  Method 

1.  Filter  on  the    following    stain  usually  known  as  Ziehl- 
Neelsen's  carbol-fuchsin  stain  : — 

Basic  fuchsin     .....           I  part. 
Absolute  alcohol         .          .          .          .10  parts. 
Carbolic  acid  in  water  (i  :  20)     .          .100  parts. 

Instead  of  the  carbolic  (i  :  20)  a  saturated  solution  of  anilin 
oil  in  water  may  be  used.  This  should  of  course  be  filtered 
previous  to  making  up. 

The  best  way  is  to  keep  in  a  stock  bottle  absolute  alcohol 
saturated  with  basic  fuchsin.  This  is  added  to  the  carbolic 
water  as  required. 

In  the  case  of  films,  hold  over  flame  or  place  upon  hot 
metal  slab  or  coin  while  steam  rises.  Remove  the  specimen 
and  repeat  the  process  twice,  the  staining  occupying  three  to 
five  minutes. 

In  the  case  of  sections,  the  above  method  may  be  used,  the 
staining  process  occupying  at  least  five  minutes. 

The  author  has,  however,  found  that  placing  the  sections 
in  the  carbol-  or  anilin -fuchsin  in  ajar  in  the  paraffin  bath  at 
50-55°  C.  gives  much  better  results,  the  tissues  being  less 
damaged  by  the  heating. 

2.  Wash  in  water. 

3.  Differentiate  in   i  per  cent  hydrochloric  acid  in  methy- 
lated spirit.       This   the  author    has  found  very  much  better 
than  the  usual  25  per  cent  H2SO4  in  water.     The  advantages 


366  APPENDIX  A 

are  that  there  is  no  danger  of  decolourising  ;  the  alcohol  test 
is  applied  to  the  organism  at  the  same  time  as  the  acid, 
and,  in  the  case  of  sections,  the  tissues  are  not  damaged 
as  they  certainly  are  by  the  stronger  acid.  Differentiation 
should  be  carried  out  until  there  is  just  a  slight  pink  tinge 
in  the  film  or  section.  Thick  portions  of  the  film  will 
probably  be  still  red,  but  in  any  case,  in  searching  for  tubercle 
bacilli,  such  thick  areas  should  be  avoided. 

4.  Wash  in  water. 

5.  Counterstain  in  a  i  per  cent  watery  solution  of  methylene 
blue  for  half  a  minute. 

With  sections,  diluted  Leishman's  stain  gives  excellent 
results.  One  part  of  Leishman's  stain  is  added  to  10  of  ordinary 
tap  water  ;  the  section  is  left  in  this  in  a  jar  over  night.  It  is 
then  differentiated  rapidly  in  acetic  acid  (i  :  1000),  dehydrated, 
cleared,  and  mounted. 

6.  In    the  case  of  films,    wash   in   water,    blot,   dry,   and 
mount. 

In  the  case  of  sections,  dehydrate  thoroughly,  thus  removing 
excess  of  methylene  blue,  clear  in  xylol  or  benzol,  and  mount 
in  balsam. 


B.  Much-Gram  Method 

1.  Stain  film  in  the  following  mixture,  either  heating  above 
the  flame  for  a  few  minutes  till  steam  rises  or  leaving  in  the 
incubator  at  37°  C.  for  twenty-four  to  forty-eight  hours  : — 

Saturated     alcoholic    solution    of    methyl 

violet  B.N.          .          .          .          .          .10  c.c. 

2  per  cent  water  solution  of  carbolic  acid.      100  c.c. 

2.  Apply  Gram's  iodine  for  one  to  five  minutes. 

3.  Drop  on  5  per  cent  nitric  acid  and  leave  for  one  minute. 

4.  Drop  on  3  per  cent  hydrochloric  acid  and  leave  for  ten 
seconds. 

5.  Differentiate  in  acetone  and  alcohol  equal  parts. 

6.  Wash  in  water. 

7.  Counterstain  in  dilute  fuchsin  if  required. 

8.  Wash,  dry. 


APPENDIX  A  367 

More  recently  Much  has  used  instead  of  2,  3,  and  4  the 
following  mixture  : — 

Potassium  iodide         .          .          .5  grm. 
2  per  cent  hydrogen  peroxide       .      100  c.c. 

The  film  is  then  differentiated  in  absolute  alcohol. 

By  either  of  the  above  methods,  in  addition  to  the  ordinary 
form  of  the  tubercle  bacillus  which  is  demonstrated  by  methods 
such  as  Ziehl-Neelsen's,  a  granular  form  of  the  organism  which 
appears  as  minute  blue-black  granules  is  shown.  This  form 
is  believed  by  many  to  be  a  resting  stage  or  spore  form  of  the 
bacillus.  The  granules  may  occur  in  a  bacillary  form  or  may 
be  found  free. 


C.  Method  combining  Ziehl-Neelsen  with  Much-Gram 
(Much-Weiss) 

i.  Stain  in  the  following  mixture  for  twenty-four  to  forty- 
eight  hours. 

Much's  carbol  methyl  violet  solution    .      i  part. 
Carbol-fuchsin 3  parts. 

Subsequently  treat  with  iodine,  nitric  acid,  etc.,  as  in  the 
Much-Gram  method. 


Method  of  demonstrating  the  Club  Form  of  Streptothrix 
Actinomyces 

These  bodies  are  exceedingly  variable  in  their  staining 
reactions.  They  are  sometimes  demonstrable  by  means  of 
Gram's  method,  but  they  are  more  often  decolourised.  The 
author  has  introduced  the  following  method,  which  has  the 
advantage  of  bringing  the  bodies  out  in  striking  contrast 
to  their  surroundings. 

The  tissues  may  be  fixed  in  either  10  per  cent  formalin  or 
in  saturated  corrosive  sublimate.  The  section  is  placed  in  the 
following  mixture,  which  is  known  as  Mann's  methyl-blue  and 
eosin  stain  : — 


368  APPENDIX  A 

i.  i  per  cent  methyl-blue  in  distilled  water  .  35  c.c. 
i  per  cent  eosin  in  distilled  water  .  .  45  c.c. 
Distilled  water  .  .  .  .  .100  c.c. 

The  section  should  be  left  in  this  for  twenty-four  hours.  A 
few  hours  would  suffice,  but  in  order  to  obtain  the  best  results, 
the  longer  period  is  necessary. 

2.  Wash  in  water. 

3.  Dehydrate  in  absolute  alcohol  to  which  a  few  drops  of  a 
i  per  cent  solution  of  caustic  potash  in  absolute  alcohol  has 
been  added. 

Treat  the  specimen  with  the  above  reagent  until  it  becomes 
a  bright  pink  colour. 

4.  Wash  in  i  per  cent  acetic  acid  in  water.     The  section 
will  now  become  bright  blue. 

5.  Wash  in  water. 

Examine  under  microscope,  and  if  necessary  repeat  3  and  4. 

6.  Dehydrate,  clear,  and  mount. 

The  above  method  is  a  slight  modification  of  Mann's 
methyl-blue  and  eosin  stain.  By  means  of  it  the  clubs  will  be 
stained  a  bright  red  colour,  while  the  cells  surrounding  them, 
as  well  as  the  mycelium  on  the  fungus,  stain  blue.  The  stain 
is  not  absolutely  specific,  as  red  blood  corpuscles  and  inflam- 
matory exudate  as  well  as  the  granules  of  eosinophil  leucocytes 
and  pancreatic  cells  react  in  a  similar  fashion. 


Method  for  staining  the  Capsules  of  Bacteria 

The  following  is  a  slight  modification  of  Muir's  capsule 
method,  suggested  by  Dr.  F.  E.  Reynolds.  It  is  useful 
for  staining  the  capsule  of  the  pneumococcus  or  pneumobacillus 
in  blood,  sputum,  or  pus  films  :  — 

1.  Stain  in  Carbol-fuchsin,  steaming,  for  one  minute. 

2.  Wash  well  in  water. 

3.  Apply  Muir's  mordant  for  one  to  two  minutes. 
Muir's  mordant  is  prepared  as  follows  : — 

Saturated  solution  of  corrosive  sublimate  .  2  parts. 
Tannic  acid  (20  per  cent  solution)  .  .  2  parts. 
Saturated  solution  of  potash  alum  .  .  5  parts. 


APPENDIX  A  369 

4.  Wash  well  in  water. 

5.  Differentiate  in  methylated  spirit  for  one  minute. 

6.  Wash  well  in  water. 

7.  Stain  in  methylene  blue  for  one  to  two  minutes, 

8.  Wash  in  water. 

9.  Dehydrate  quickly  in  absolute  alcohol. 

i  o.   Clear  in  xylol  or  benzol  for  five  minutes. 
ii.   Mount  in  Canada  balsam. 

By  this  method  the   organisms  are  stained  red,  while  the 
capsules  of  the  bacteria,  the  pus  cells,  etc.,  are  stained  blue. 


Hiss's  Method 

1.  Stain  in  the  following  mixture,  heating  for  a  few  seconds 
over  the  flame  until  steam  rises. 

Saturated  alcoholic  solution  of  acid  fuchsin        .        i  part. 
Distilled  water 19  parts. 

2.  Wash  off  the  staining  fluid  with  a  20  per  cent  solution 
of  copper  sulphate. 

3.  Without  washing  in  water  dry  with  filter  paper. 

By  this  method  the  capsules  of  organisms  growing  in  both 
as  well  as  these  in  blood  and  pus  films  can  be  demonstrated. 


Methods  for  demonstrating  Spirochsetes 

In  Films — 

1 i )  Giemstfs  Method. 

1.  Make  a  thin  film  of  the  fluid  to  be  examined. 

2.  Fix  it  in  absolute  alcohol  for  fifteen  minutes. 

3.  Dilute  Giemsa's   stain   by  adding   10  drops  to   10  c.c. 
distilled  water  and   pour  over  film,  leaving  for  ten  to  thirty 
minutes. 

4.  Wash  well  in  a  stream  of  water  and  dry. 

(2)  Burros  Ink  Method. 

For  this  purpose  a  little  "  Chin-chin,  Pelican "  ink  is 
mixed  with  an  equal  quantity  of  distilled  water.  This  mixture 
should  be  sterilised  in  the  autoclave  and  allowed  to  sediment 
for  some  time  (two  weeks).  It  is  then  decanted  off  the 


370  APPENDIX  A 

sediment.  With  a  platinum  needle  a  small  quantity  of  the 
fluid  to  be  investigated  is  mixed  with  a  little  of  the  ink  on  a 
clean  slide  and  a  film  made.  This  is  allowed  to  dry  and  is 
then  examined  with  the  oil  immersion  lens. 

In  Tissues — 

For  this  purpose  Levaditi's  method  gives  excellent  results. 

1.  Thin  pieces  of  the   tissues  are  placed   in   10  per  cent 
formalin  for  twenty-four  hours. 

2.  Transfer  to  96  per  cent  alcohol  for  twenty-four  hours. 

3.  Place  in  distilled  water  until  they  sink. 

4.  Transfer  to   1^-3  per  cent  solution  of  silver  nitrate  in 
distilled  water  and  leave  there  for  three  days  in  the  incubator 
at  37°  C. 

5.  Wash  rapidly  in  distilled  water. 

6.  Reduce  by  placing  for   twenty-four  to  forty-eight  hours 
at  room  temperature  in  the  dark  in 

Pyrogallic  acid          .          ...      4  grm. 
Formalin  (40  per  cent)     .          .  5  c.c. 

Distilled  water          .          .          .          .      100  c.c. 

7.  Wash  in  water. 

8.  Embed  in  paraffin  or  celloidin. 

After  cutting,  the  paraffin  sections  merely  require  solution  of 
the  paraffin  and  mounting  in  balsam. 

By  this  method  the  spirochaetes  appear  black,  from  the 
silver  which  is  precipitated  in  their  substance. 


EXAMINATION   OF   SPUTUM,    PUS,    ETC., 
FOR   THE   TUBERCLE   BACILLUS 

The  sputum  should  be  poured  into  a  Petri  dish,  and  by 
means  of  sharp-pointed  forceps  and  scissors  a  suitable  portion 
is  removed  and  placed  upon  a  clean  slide.  A  second  slide  is 
placed  upon  the  top  of  the  first  and  the  sputum  spread  out  by 
pressing  the  slides  together.  The  two  slides  are  then  slid 
apart  and  the  two  films  dried  and  fixed  in  the  flame.  Suitable 
portions  for  examination  are  any  rounded  yellow  or  white 


APPENDIX  A  371 

masses,  or,  in  the  absence  of  these,  opaque  white  streaky 
material.  Both  slides  are  then  stained  with  carbol-fuchsin  for 
three  to  five  minutes,  the  stain  being  heated  until  the  steam 
rises.  A  convenient  way  of  doing  this  is  to  heat  a  penny  in  the 
flame  and  then  place  the  slide  covered  with  carbol-fuchsin  upon 
the  coin.  Where  a  number  of  slides  have  to  be  stained  at  once 
a  useful  method  is  to  place  two  pieces  of  glass  tubing  across  a 
sink  ;  the  slides  are  then  placed  across  these,  the  stain  is  filtered 
on,  and  the  slides  heated  by  playing  a  bunsen  flame  on  them 
from  below.  Having  been  stained,  the  films  are  washed  in 
water  and  differentiated  in  a  i  per  cent  mixture  of  hydrochloric 
acid  and  methylated  spirit.  This  medium  for  differentiating 
has  the  advantage  that  the  alcohol  and  acid  test  are  applied  at 
one  and  the  same  time.  The  slide  is  then  washed  in  water, 
counter-stained  in  methylene  blue  (i  per  cent  watery),  washed 
again  in  water,  dried,  and  examined  under  the  oil  immersion. 
It  is  well  to  examine  both  slides  systematically  from  one  end  to 
the  other. 

Pus  or  caseous  material  may  be  examined  in  a  similar  way. 

The  reason  for  differentiating  with  acid  is  because  a  majority 
of  organisms,  after  staining  in  carbol-fuchsin  and  heating,  are 
readily  decolourised  with  dilute  acid.  The  tubercle  bacillus 
and  other  germs,  such  as  the  bacillus  of  leprosy,  the  smegma 
bacillus,  the  Timothy-grass  bacillus,  the  butter  bacillus,  etc.,  are 
not  decolourised  with  dilute  acid.  They  thus  form  a  group  of 
acid-fast  bacilli.  Spirit  or  alcohol  forms  another  differentiating 
medium,  because  the  tubercle  bacillus  resists  it,  whereas  the 
smegma  bacillus  is  decolourised. 


Concentration  Method  for  Sputum,  Pus,  etc. 

Add  to  the  sputum,  pus,  etc.  an  equal  quantity  of  50  per 
cent  antiformin. 

Antiformin  may  be  made  up  as  follows  : — 


Solution  i 

Sod.  carb 10  grm. 

Calx  chlorinata  (bleaching  powder)         .  50  grm. 

Dist.  water  100  c.c. 


372  APPENDIX  A 

Solution  2 

Sod.  hydrate         .          .  1 5  grm. 

Dist.  water.          .          .          .      icoc.c. 

For  use  mix  equal  parts  of  i  and  2,  and  dilute  with 
equal  quantity  of  water. 

The  mixture  is  then  shaken  thoroughly  and  allowed  to 
remain  for  two  to  twenty-four  hours.  At  the  end  of  that  time 
it  will  form  a  more  or  less  homogeneous  fluid.  This  may  be 
centrifugalised  at  once  and  the  deposit  examined  by  staining, 
or  Eurich's  method  may  be  employed  as  follows  : — Acetone 
and  ether  (equal  parts)  are  shaken  up  with  the  antiformin 
mixture  in  a  narrow  glass  vessel.  The  fluids  will  then  separate 
into  two  layers,  the  acetone  and  ether  being  above,  and  at  the 
point  of  junction  a  white  precipitate,  which  contains  the  larger 
proportion  of  any  cellular  debris  in  the  sputum,  also  the 
micro-organisms  and-  among  these  the  tubercle  bacilli.  The 
precipitate  is  easily  removed  (after  pipetting  of!  the  ether) 
by  means  of  a  glass  pipette  and  rubber  teat.  Films  are 
made  from  this,  stained,  and  examined.  In  cases  where  no 
precipitate  forms  at  the  junction  of  the  fluids,  the  acetone 
and  ether  should  be  decanted  off,  and  some  of  the  antiformin 
mixture  centrifugalised.  Films  are  made"  from  the  deposit. 
Should  such  deposit  be  found  difficult  to  spread  on  a  slide, 
a  little  of  the  original  sputum  mixed  with  it  will  assist  matters. 

Caseous  tissue  should  be  cut  up  into  thin  shreds  by 
sectioning  with  the  freezing  microtome  and  the  resulting  pulp 
treated  with  antiformin  and  centrifugalised.  The  deposit  is  then 
smeared  on  slides  and  stained  by  the  Ziehl-Neelsen  or  Much- 
Gram  method. 

Care  should  always  be  taken  to  see  that  any  distilled  or 
tap  water  used  in  carrying  out  these  processes  is  itself  free 
from  acid-fast  organisms. 


THE  BACTERIOLOGICAL   DIAGNOSIS   OF 
DIPHTHERIA 

It    may  be    necessary  in    some    fatal  cases   of  disease  to 
ascertain  whether  or  not  diphtheria  bacilli  are  present  in  the 


APPENDIX  A  373 

fauces,  tonsils,  or  mucous  membrane  of  the  air  passages.  The 
method  of  diagnosis  is  the  same  as  in  the  case  of  the  living 
subject,  and  should  be  carried  out  as  follows  : — 

(a)  Films  should  be  made  from  suspicious  exudate  in  any 
of  the  above  situations  and  stained  by  (i.)  Gram's  method  ;  (ii.) 
carbol-thionin  blue  ;  (iii.)  Neisser's  method  (see  below).  Char- 
acteristic organisms  may  or  may  not  be  found.  If  none  are 
seen,  cultures  should  be  made. 

(b)  A  sterile  swab  or  platinum  needle  is  rubbed  over  the 
surface  of  any  exudate  which  may  be  present.  If  no  exudate 
is  present,  the  secretion  covering  the  tonsil  is  removed  and 
smeared  over  the  surface  of  a  tube  of  blood  serum  or  blood 
agar.  This  is  incubated  at  blood  heat  for  12  to  24  hours. 
Films  are  then  made  from  the  growth  which  develops,  and 
stained  by  the  above  methods. 


Neisser's  Staining  Method  for  the  Diphtheria  Bacillus 

Solutions 

A.  Methylene  blue  (Griibler),  i  grm.,  dis- 

solved in  20  c.c.  of  96  per  cent  alcohol. 
Add  to  this  950  c.c.  of  distilled  water 
and  50  c.c.  glacial  acetic  acid. 

B.  Bismarck-brown  (Vesuvin)       .     2  grm. 
Distilled  water       .         .  i  litre. 

Method. 

Stain  films  for  one  to  three  seconds  in  A,  pour  off  the 
excess  of  stain  and  blot.  Drop  on  B  and  leave  for  three  to 
nine  minutes.  Wash,  dry,  and  examine. 

By  this  method  the  body  of  the  diphtheria  organism  is 
stained  brown  while  the  granules  are  dark  blue. 

A  modification  of  the  method  is  as  follows  : — 

Prepare  two  staining  fluids  : 

A.   Methylene  blue     .  .  i  grm. 

96  per  cent  Ale.    .  .  .20  c.c. 

Glacial  acetic  acid  .  .      50  c.c. 

Distilled  water     .  .  .      i  litre. 


374  APPENDIX  A 

B.   Crystal  violet  (Hochst).          .      i  grm. 

Abs.  ale 10  c.c. 

Distilled  water     .          .          .      300  c.c. 
Mix  two  parts  of  A  with  one  of  B. 
Method. 

1.  Stain  in  mixture  for  about  ten  seconds. 

2.  Wash  in  water. 

3.  Stain  in  cresoidin  (2  grm.  in  300  c.c.  water)  for  about  ten 
seconds  (the  stain  should  be  dissolved  in  hot  water  and  filtered). 

4.  Wash,  dry,  and  mount. 

The  appearance  of  the  organism  is  the  same  as  with  the 
first  method. 


AGGLUTINATION   TEST   FOR   ORGANISMS 

It  is  sometimes  necessary  to  carry  out  an  agglutination  test 
in  the  case  of  an  organismal  condition  such  as  typhoid  fever 
(Widal  reaction),  or  in  cases  of  suspected  meat  poisoning  (see 
p.  314)  ;  the  serum  of  the  individual  being  tested  as  regards 
its  agglutinating  power  against  the  germ  or  germs  cultivated 
from  the  lesion  or  from  intestinal  contents  or  against  stock 
cultures  of  known  organisms. 

The  method  of  carrying  out  the  test  is  as  follows  : — 

1.  The  serum  of  the  case  is  secured  by  centrifugalising  a 
quantity  of  blood  or  blood-clot  obtained  from  the  heart  and 
pipetting  off  the  supernatant  fluid.     This  is  mixed  with  normal 
saline  solution  by  means  of  a  graduated  pipette  so  as  to  make 
dilutions  of  i  in  5,  i  in  20,  and  i  in  40,  etc. 

Another  method  is  to  prepare  a  capillary  pipette  (see  below), 
make  a  mark  upon  it  with  a  grease  pencil,  and  draw  up,  by 
means  of  a  rubber  teat,  to  the  mark  one  portion  of  the  serum 
and  subsequently  four  portions  of  the  normal  saline  solution, 
allowing  a  bubble  of  air  to  intervene  between  the  various 
portions.  These  are  then  blown  out  and  mixed  in  a  watch 
glass,  thus  forming  a  dilution  of  one  in  five.  From  this  the 
other  dilutions  can  be  made  in  a  similar  fashion. 

2.  kpure  culture  on  solid  medium,  e.g.  agar  slope,  of  the 
organism   against   which  it   is   desired   to  test   the   serum   is 
obtained.     An  emulsion  is  made  by  mixing  some  of  the  growth, 


APPENDIX  A  375 

removed  by  a  platinum  needle,  in  normal  saline,  thus  making  a 
solution  with  a  distinctly  opalescent,  but  not  too  turbid,  appear- 
ance. This  is  allowed  to  settle  for  an  hour,  or  centrifugalised 
for  a  few  minutes,  in  order  to  get  rid  of  any  clumps  of  bacteria. 
A  slide  with  a  hollow  in  the  centre  is  then  taken  and 
smeared  round  the  margin  of  the  hollow  with  vaseline.  A 
cover  slip  is  cleaned,  and  by  means  of  a  platinum  loop  a 
minute  spot  of  the  serum  ( I  in  five)  and  one  of  the  emulsion  are 
placed  side  by  side  on  the  cover  glass,  and,  after  heating  the 
loop  in  order  to  dry  it  and  allowing  it  to  cool,  the  two  are  mixed 
together.  The  cover  slip  is  then  lifted  with  a  pair  of  forceps, 
turned  over,  and  placed  upon  the  slide  so  that  the  drop  hangs  in 
the  hollow.  The  slide  is  examined  under  a  J  objective,  care 
being  taken  to  cut  off  the  greater  part  of  the  light  coming  from 
the  mirror  of  the  microscope,  by  means  of  the  iris  diaphragm. 
The  organisms  will  usually  be  seen  as  minute  highly  refractile 
bodies,  darting  hither  and  thither.  Similar  hanging- drop 
preparations  should  be  made  with  the  other  dilutions  of  the 
serum.  Dilutions  of  I  in  10,  i  in  40,  and  I  in  80  are  thus 
obtained.  Control  preparations  may  also  be  made  with  a 
normal  serum. 

After  examining  the  slides  under  the  microscope  to  see  that 
the  bacteria  are  visible  and  motile  they  should  be  placed  in 
the  incubator  and  again  examined  after  one-half  to  one  hour. 
The  presence  of  clumps  of  motionless  bacteria  is  indicative  of 
a  positive  reaction.  At  the  same  time  a  positive  result  with  a 
dilution  of  I  in  10  should  be  neglected  unless  there  is  agglutina- 
tion in  the  higher  dilutions  as  well. 

In  the  absence  of  the  hollow  slides,  ordinary  slides  may 
be  used. 

METHOD  OF  MAKING  PIPETTES  FOR  REMOVING 
FLUIDS,  ETC. 

Mark  off  a  section,  6-8  inches  long,  of  soft  glass  tubing 
(J  inch  bore)  with  a  file  and  break  it  across.  This  is  held  in 
the  hands  so  that  the  centre  lies  in  the  flame  of  a  blow-pipe 
or  an  ordinary  Bunsen  burner,  the  tubing  being  constantly 
turned  between  the  fingers  so  that  the  flame  plays  upon  all  sides 
of  it.  No  attempt  should  be  made  to  draw  the  two  ends 


376  APPENDIX  B 

apart  until  the  central  portion  is  quite  soft.  When  this  has 
been  effected,  the  tube  is  withdrawn  from  the  flame,  and  very 
slowly  the  two  ends  are  separated,  until  a  capillary  tube  of  at 
least  12  inches  long  has  been  made.  The  tubing  should  be 
held  in  the  same  position  until  it  has  cooled  sufficiently  to 
prevent  it  bending.  It  is  then  broken  across  in  the  centre, 
thus  forming  two  pipettes.  The  end  of  the  pipette  should  be 
passed  through  the  flame  before  using  for  the  removal  of 
exudate,  blood,  etc.  A  rubber  teat  attached  at  the  broad  end 
will  enable  the  operator  to  withdraw  a  considerable  quantity 
of  fluid. 

APPENDIX   B 
EMBALMING 

In  cases  where  bodies  have  to  be  sent  long  distances,  it 
may  be  necessary  to  inject  a  preservative  into  the  circulation 
in  order  to  stay  the  progress  of  putrefaction.  The  simplest 
fluid  for  the  purpose  is  made  up  as  follows  : — 

Formalin      .          .          .          .          -4  pints. 
Acid-carbolic  (cryst.)     .          .  I  Ib. 

Water          .          .          .          .          .2  gallons. 

This  fluid,  to  the  amount  of  two  gallons  (in  the  case  of  an 
adult  male),  should  be  introduced  by  means  of  a  cannula  into 
the  femoral  artery  or  abdominal  aorta.  The  time  selected  for 
the  operation  should  be  at  least  twenty-four  hours  after  death, 
i.e.  at  a  time  when  rigor  mortis  has  just  passed  off.  If  the 
femoral  artery  is  selected,  the  injection  should  be  made  in 
Scarpa's  triangle,  and  the  nozzle  of  the  injector  directed 
upwards  towards  the  heart. 

If  a  post-mortem  examination  has  to  be  performed  in 
addition,  this  should  be  carried  out  at  least  twenty-four  hours 
after  the  injection. 

Preservative  fluid  should  also  be  introduced  into  the 
stomach,  intestines,  bladder,  pleura,  and  other  spaces. 

The  surface  of  the  body  may,  in  addition,  be  washed  with 
a  saturated  solution  of  corrosive  sublimate  in  methylated  spirit 
mixed  with  five  times  the  amount  of  glycerine.  (C.  R.  Box, 
Post-Mortem  Manual.) 


INDEX 


Abdominal  contents,  examination 

of,  28 
Abscess,  cerebral,  240 

actinomycotic,  182 

association     with     pulmonary 
disease,  241 

of  liver,  181 

of  lung,  131 

tropical,  182 

Absolute  alcohol,  as  fixative,  329 
Acid  alcohol,  339 
Acromegaly,  260 
Actinomycosis  of  liver,  182 

of  intestine,  1 66 

of  mouth,  153 
Acute    yellow    atrophy    of   liver, 

182,  183,  270 
Addison's  disease,  114 
Adeno- carcinoma,  299 

of  breast,  273 

of  intestine,  171 

of  liver,  192 

of  stomach,  158 
Adenoma,  285 

malignant,  300 

of  breast,  273 

of  thyroid,  112 
Agglutination  test  for  organisms, 

374 

Agonal  thrombi,  63 
Albumose,  Ben ce- Jones,  293 
Alimentary  tract,  parasites  of,  170 
Alveolar  sarcoma,  292 
Ammonia  carmine,  351 
Ammonia  gas,  poisoning  from,  314 
Amoebic  dysentery,  168 


Amyloid,  stains  for,  352 
Amyo trophic  lateral  sclerosis,  250 
Anaemia,  pernicious,  93 
Anasarca,  217 
Aneurysm,  causes  of,  87 

dissecting,  85 

effects  on  surrounding  parts,  86 

false,  85 

fusiform,  85 

miliary,  85 

rupture  of,  86 

saccular,  85 

sites  of,  85 

types  of,  85 
Angio-sarcoma,  293 
Angioma,  cavernous,  281 

lymph,  282 

plexiform,  281 
Anilin  stains  for  waxy  material, 

353 

Anthracosis  of  lung,  133 
Anthrax,  2 
Antiformin,  371 
Antrum,  maxillary,    examination 

of,  41 
Aorta,  abnormalities  of,  48 

atheroma  of,  79 

congenital  stenosis  of,  47 

examination  of,  23 
Aortic  valve,  diseases  of,  71,  72 

effects  of  disease  of,  71 
Apoplexy,  cerebral,  237 

pulmonary,  123 
Appendicitis,  169 
Arteries,  calcareous  degeneration 
of,  78 


377 


378 


INDEX 


Arteries,  diseases  of,  77 

fatty  degeneration  of  intima  of, 
78 

hypertrophy  of  media  of,  80 

inflammation  of,  78 

waxy  degeneration  of,  78 
Arteries  in  nephritis,  216 

in  syphilis,  84 

in  tuberculosis,  84 
Arteriosclerosis,  78 
Arteriosclerotic  kidney,  214 
Artery,     pulmonary,     congenital 
stenosis  of,  47 

pulmonary,     examination     of, 

23 
Arthritis,  acute,  261 

rheumatoid,  262 

suppurative,  261 

tuberculous,  261 
Aschoff-Becker  microtome,  334 
Aschofif  on  gall  stones,  195 
Ascites,  172 

chylous,  172 
Atelectasis  of  lung,  120 
Atheroma,  79 

aneurysm  from,  81 

calcareous  deposit  in,  79 

causes  of,  82 

diffuse,  79 

effects  of,  8 1 

interstitial  nephritis  in,  81 

nodular,  79 

syphilitic,  80 

thrombosis  in,  81 
Atherosclerosis,  79 
Atrophy,  brown,  of  heart,  54 

yellow,  of  liver,  182,  183 

progressive  muscular,  249 
Auriculo-ventricular  bundle,  73 
Autopsy,  i 

B.  diphtheria,  stain  for,  373 
B.  pestis,  staining  of,  364 
Bacteria,  acid-fast,  362 
stain  for  (acid- fast),  365 
carbol-thionin    blue    stain    for, 

364 
eosin  methylene  blue  stain  for, 

364 
Gram's  stain  for,  363' 


Bacteria,    Gram-Weigert's    stain, 
363 

methods  of  staining,  362 

staining  of  capsules,  368 
Bacteriological     investigation, 
methods  of,  358 

capillary  pipettes,  375 

for  diphtheria,  372 

of  blood,  359 

of  hollow  viscera,  360 

of  serous  sacs,  361 

of  solid  organs,  360 

requisites  for,  358 
Ball  thrombus,  63 
Banti's  disease,  95 
Barlow's  disease,  99 
Base  of  skull,  Harke's  saw-cut  for, 

4i 

Bence- Jones  albumose,  293 
Best's  method  of  demonstrating 

glycogen,  351 

Bile  ducts,  diseases  of,  194 
inflammation  of,  194 
obliteration  of,  194 
obliteration  of  in  fine  cirrhosis, 

194 

suppuration  of,  195 
Bile    and    pancreatic    ducts,    ex- 
amination of,  31 
Biliary  concretions,  195 
Bladder,  urinary,  diseases  of,  227 
tumours  of,  228 
calculi  of,  228 
Bladder  and  urethra,  examination 

of,  33 

removal  of,  33 

Blood,    bacteriological    examina- 
tion of,  359 
diseases  of,  91 
in  carbon  monoxide  poisoning, 

3i3 

in  nephritis,  217 

post-mortem  examination  of,  91, 
358 

test  for  carbon  monoxide  in,  314 
Blood-film,  making  of,  357 
Blood-vessels,  diseases  of,  77 
Body,  external  examination  of,  13 

indentification  of,  307 

toilet  of,  44 


INDEX 


379 


Bone,  osteitis  deformans,  260 

syphilis  of,  260 

tuberculosis  of,  259 

tumours  of,  260 

Bone    marrow,    degeneration    of, 
1 02 

diseases  of,  100 

erythroblastic,  101 

examination  of,  100 

functions  of,  101 

in  pneumonia,  129 

leucoblastic,  101 

pigmentary  changes  in,  102 
Bowels,  examination  of,  28 

diseases  of,  159 
Brain,   circulatory  disturbances, 

233 

diseases  of,  229,  233 

embolism  of,  235 

examination  of,  38 

gumma  of,  242 

hydrocephalus  of,  234 

inflammation  of,  240 

osdema  of,  233 

removal  of,  35,  37 

syphilis  of,  241 

thrombosis  of,  235 

tuberculosis  of,  241 

tumours  of,  242 
Breast,  diseases  of,  272 
Bright' s  disease,  207 
Bronchi,  dilatation  of,  119 

diseases  of,  117 

examination  of,  28 
Bronchiectasis,  119 
Bronchiolectasis,  119 
Bronchitis,  acute,  117 

chronic,  118 

syphilitic,  119 

tuberculous,  118 
Bronchocele,  112 
Broncho- pneumonia,  129,  130 
Broncho-pneumonia,        purulent, 

130 

"  Brown  atrophy  "  of  heart,  54 
"  Brown  induration  "  of  lung,  123 
Bruce  microtome,  333 
Bum's  ink  stain  for  spirochaetes, 

369 
"  Button-hole,"  mitral,  69 


Caisson  disease,  246 

Calcareous  degeneration  of  media, 

78 

Calcareous   material,  staining  of, 
352 

Von  Kossa  silver  stain  for,  352 
Calculus,  biliary,  195 

urinary,  228 

Calvarium,  removal  of,  36 
Canada  balsam,  336 
Cancer,  general  use  of  term,  286 
"  Cancer  bodies,"  297 
Cancers,  295 
Canon  on  bacteria  in  peripheral 

veins,  360 

Capsule  stains  for  bacteria,  368 
Carbol-fuchsin  stain,  365 
Carbol-thionin  blue  stain  for  bac- 
teria, 364 
Carbolic  oil   in   place   of  rubber 

gloves,  6 

Carbon  monoxide  poisoning,  313 
Carcinoma,  adeno-,  299 

colloid,  302 

columnar  cell,  300 

differences  from  sarcomata,  295 

encephaloid,  302 

general  characteristics  of,  295 

glandular,    general     character- 
istics of,  300 

inclusions,  297 

medullary,  302 

metastases,  296 

of  bladder,  228 

of  bone,  261 

of  brain,  224 

of  breast,  273 

of  gall  bladder,  197 

of  heart,  60 

of  intestine,  171 

of  kidney,  223 

of  larynx,  117 

of  liver,  192 

of  lung,  148 

of  lymph  glands,  105 

of  pancreas,  198 

of  prostate,  274 

of  spinal  cord,  252 

of  stomach,  158 

of  suprarenal,  115 


38o 


INDEX 


Carcinoma  of  thyroid,  112 

of  uterus,  268 

scirrhous,  301 

sites  of,  295,  297 

soft,  302 

spheroidal  cell,  301 

spread  to  glands,  296 

types,  295 

ulceration  of,  295 
Capsules,  staining  of,  368 
Cathcart,  freezing  microtome,  334 
Cavernous  angioma,  281 
"  Cell  nest,"  298 
Celloidin,  embedding  in,  332 

sections,  cutting,  333 

staining  of,  338 
Cerebral  haBmorrhage,  237 

artery  of,  238 

causes  of,  237 

site  of,  238 

types  of,  237 

Cerebro-spinal  fluid,  excess  of,  234 
Cerebro-spinal  meningitis,  231 
Chalicosis  of  lung,  133 
Charcot's  joint,  262 
Cheloids,  277 
Chest,  barrel-shaped,  15 

pigeon,  15 

Chloroform  poisoning,  314 
Chloroma,  98 

blood  in,  99 
Cholangitis,  194 

suppurative,  181 
Cholecystitis,  194 
Cholelithiasis,  195 
Cholera,  163 
Cholesteatoma,  244 
Chondroma,  279 
Chondro-sarcoma,  292 
Chorea  gravidarurn,  269 
Chorionepithelioma,  268,  304 
Chromaffin  cells,  staining  of,  354 
Chromatophore  cells  in  melanotic 

tumours,  294 

Chronic    venous    congestion,    of 
intestine,  161 

of  kidney,  201 

of  liver,  175 

of  lung,  122 

of  myocardium,  56 


Chronic    venous    congestion,     of 
spleen,  107 

of  stomach,  155 

in  valvular  disease,  70 
Cirrhosis,  acute,  183,  185 

atrophic,  186 

biliary,  188 

common,  187 

hyper  trophic,  186 

monolobular,  186 

of  liver,  185 
results  of,  189 

polylobular,  186 

syphilitic,  189 

Clots,  agonal,in  pulmonary  artery, 
23 

post-mortem,  61,  62 
Cloudy  swelling  of  heart,  54 

of  kidney,  202 

of  liver,  176 
CO2  for  freezing,  334 
Coal-gas  poisoning,  313 
"  Coal  miner's  lung,"  133 
Colitis,  167 

mucous,  169 
Collapse  of  lung,  119,  120 

medico-legal,  310 
Colliquative  necrosis,  235 
Colloid  cancer,  302 
Colophonium  as  mountant,  337 
Colour,  preservation  of  in  mount- 
ing specimens,  319 
Columnar  cell  carcinoma,  300 
Compound  cystic  adenoma,  264 
Concentration  method  of  examin- 
ing pus  and  sputum,  371  > 
Congenital  cystic  kidney,  200 
Cornet's  forceps,  336 
Coronary  arteries,  anatomy  of,  26 

effects  of  obstruction,  56 

narrowing  of,  57 
"  Corona  veneris,"  260 
Coroner,  2,  3,  307 
Corpora  amylacea  in  prostate,  274 
Corpus  luteum,  264 
Corrosive  sublimate,   as  fixative, 

328. 

Cover  glasses,  cleaning  of,  336 
Cretinism,  in 
Cuboid,  ossific  node  in,"  310 


INDEX 


Culture    tubes,    innoculation    of, 

359 

Cutting  paraffin  sections,  332 
Cutting  sections  in  celloidin,  333 
Cutting  sections  in  gum,  333 
Cyanide  poisoning,  314 
Cystic  adenoma,  285 
Cysts  of  pancreas,  199 

Death,   causes  of  in  infanticide, 

3ii 

causes  of  in  new-born,  311 

sudden,  26,  28,  77,  114 
Decalcification  of  tissues,  335 
Decalcifying  fluid,  335 
Deciduoma  malignum,  268 
Degeneration,     fatty,    of     endo- 
cardium, 60 

fatty,  of  heart,  55,  60 

fatty,  of  kidney,  202 

fatty,  of  liver,  177 

fatty,  of  myocardium,  55 

Zenker's,  18 

waxy,  of  liver,  179 

waxy,  of  kidney,  203 

waxy,  of  spleen,  105 
Dehydration  of  tissue  for  micro- 
scopic sections,  330 
"  Deposition,"  medico-legal,  308 
Dermoid  cyst,  265,  303 
Developmental  changes  in  foetus, 

309 

Dextrocardia,  48 
Diabetes,  pancreas  in,  199 
Diffuse-waxy  spleen,  106 
Digestion,  post-mortem,  155 
Dilatation  of  heart,  60 
Diphtheria  of  mouth,  153 

method  of  examination,  372 
Disseminated  sclerosis,  250 
Dropsy,  217 

in  cardiac  disease,  72 

of  peritoneum,  172 

of  pleura,  149 

renal,  217 
Ductus  arteriosus,  persistence  of, 

47 
Duodenum,  examination  of,  30 

ulcer  of,  157 
"  Dust  diseases,"  133 


Dysentery,  amoebic,  167,  168 
bacterial,  167 

Eclampsia,  270 

kidney  in,  271 

liver  in,  179,  271 
Ectopic  gestation,  265,  269 
Egyptian  mummies,  4 
Ehrlich's  stain  for  glycogen,  349 
Elastic  tissue  stain,  343 
Embalming,  376 
Embedding  in  celloidin,  332 

in  gum,  326 

in  paraffin,  330 
quick  method,  331 
summary  of,  332 
Emboli,  septic,  of  lung,  131 
Embolism    from    acute    endocar- 
ditis, 68 

of  brain,  235 

of  intestine,  161 

of  kidney,  201 

of  liver,  176 

of  lung,  123 

of  portal  vein,  176 

of  spleen,  108 

of  uterine  veins,  266 

pulmonary,  123,  269 
Emphysema  of  lung,  121 
Empyema,  150 

of  gall  bladder,  195 
Encephalitis,  suppurative,  240 
Encephaloid  cancer,  302 
Endarteritis,  in  brain  syphilis,  242 

deformans,  79 

obliterans,  83 

proliferans,  83 
Endocarditis,  acute,  64 

acute  results  of,  67 

chronic,  68 

difference  between  simple  and 
ulcerative,  table  of,  67 

results  of  chronic,  68 

simple  acute,  65 

ulcerative,  66 

in  pneumonia,  129 
results  of,  66 
Endocardium,  atheromatous,  61 

calcareous  deposits  in,  61 

diseases  of,  60 


382 


INDEX 


Endocardium,  fatty  degeneration 
of,  60 

red  staining  of,  60 
Endometritis,  acute,  266 

chronic,  267 

tuberculosis,  267 
Endotheliomata,  292 
Entamoeba  hystolytica,  stain  for, 

364 

dysentery  due  to,  167 
Enteritis,  162 

acute,  162 

tuberculous,  165 

typhoid,  165 
Eosin,  339 

methylene    blue,    Mallory    and 
Wright's  method,  342 
stain  for  bacteria,  364 
staining  method,  341 
Epithelioma,  squamous,  297 

of  gall  bladder,  197 

of  intestine,  171 

of  oesophagus,  154 

of  stomach,  158 

of  uterus,  268 
Epulis,  malignant,  291 
Equipment  of  pathologist,  5 
Ether  for  freezing,  334 
Examination  of  abdominal   con- 
tents, 28 

of  aorta,  23 

of  bile  and  pancreatic  ducts,  31 

of  bladder  and  urethra,  33 

of  brain,  35,  38 

of  bronchi,  28 

of  duodenum,  30 

of  eye  and  orbit,  40 

of  gall  bladder,  31 

of  heart,  23 

of  intestines,  29 

of  kidneys,  34 

of  liver,  31 

of  lungs,  27 

of  maxillary  antrum,  41 

of  middle  ear,  40 

of  pancreas,  32 

of  plural  cavities,  19 

of  sinuses  of  head,  40 

of  spinal  cord,  39 

of  spleen,  32 


Examination  of  stomach,  30 

of  suprarenals,  33 

of  surface  of  heart,  24 

of  testicles,  35 

of  thoracic  contents,  23 

of  thoracic  duct,  35 

of  thyroid  gland,  28 

of  uterus,  34 

of  valves  of  heart,  24,  25,  26 

of  venaa  cavae,  23 

of  vermiform  appendix,  30 
Exostosis,  280 
Eye  and  orbit,  examination  of,  40 

Fallopian  tubes,  diseases  of,  265 
Farrant's  medium  for  mounting, 

337 
Fat  necrosis,  197 

Nile  blue  sulphate  stain  for,  347 
osmic  acid  stain  for,  347 
Scharlach  R.,  stain  for,  348 
staining  by  haematoxylin,  347 
Sudan  III.  stain  for,  348 
Fat  in  tissues,  staining  of,  346 
Fatty    change    in     phosphorous 

poisoning,  313 
degeneration    of    endocardium, 

60 

of  heart,  54 
of  intima,  78 
of  kidney,  202 
of  liver,  177 
of  myocardium,  55 
infiltration  of  heart,  54 

of  liver,  178 
loading  of  heart,  54 
Femur,  ossific  node  in,  310 
Fever,  puerperal,  269 
Fibrin  staining  method,  345 
Fibro- adenoma,  285 
Fibro-myoma,  280 

of  uterus,  268 
Fibroid  phthisis,  144 
Fibroid,  recurrent,  287 
Fibroma,  277 

in  ovary,  265 

Fibromatosis  of  stomach,  158 
Fibrosis  of  lung,  146 
Fixation    of   nervous    tissue    for 
microscopic  sections,  325,  327 


INDEX 


383 


Fixative,  absolute  alcohol,  329 

corrosive  sublimate,  328 

Flemming's,  325,  328 

Jores's,  323 

Kaiserling's,  323 

Marchi's,  325,  328 

methylated  spirit,  329 

Miiller's,  327 

Orth's,  328 

Pick's,  322 

Zenker,  327 
Fixing  paraffin  sections  on  slides, 

332 
Flemming's  fixative,  325 

solution,  328 
Flies  at  post-mortem,  7 
Focal  necrosis,  178 
Foetus,    table   of,    developmental 

changes  in,  309 
Formalin,  Schering's,  323 
Fracture    of    skull,    examination 

for,  35 

Freezing  gum  sections,  334 
Friedreich's  ataxia,  252 
Frost's  preservative,  323 
"  Fuchsin  bodies,"  297 

Gall  bladder,  diseases  of,  194 

empyema  of,  195 

examination  of,  31 

inflammation  of,  194 

suppuration  of,  195 

tumours  of,  197 
Gall  stones,  types  of,  195 
Ganglion  cells,  staining  of,  356 
Gangrene  of  lung,  131 
Gastrectasis,  155 
Gastritis,  suppurative,  156 
Gelatine  fluid  for  mounting  speci- 
mens, 322 

General  paralysis  of  insane,  242 
Gentian  violet  stain,  353 
Giant  cell  sarcoma,  291 
Giemsa's  stain  for  spirochaetes,  369 
"  Gin-drinker's  "  liver,  187 
Glioma,  282 

Glio-sarcoma,  243,  283,  292 
Gliosis  of  spinal  cord,  245 
Gloves,  rubber,  cleansing  of,  44 
care  of,  15 


Glycerine  jelly,  337 
Glycogen,  Best's  method  of  stain- 
ing, 351 

Lubarsch's  method  of  demon- 
strating, 350 
in    tissues,    demonstration    of, 

349 
Ehrlich  method  of  staining, 

349 
Goitre,  112 

exophthalmic,  112 

simple,  112 
Gout,  262 
Gram's      method      of      staining, 

363 

Grave's  disease,  112 
Grey  hepatization  of  lung,  127 
Gum,  cutting  sections  in,  333 

sections,  staining  of,  338 
Gumma,  of  bone,  260 

of  brain,  242 

of  heart,  59 

of  liver,  190 

of  lung,  135 

of  spinal  cord,  252 

of  testicle,  273 

Haemangioma,  281 
Haematein,  eosin  stain,  339 
Haematothorax,  149 
Haematoxylin,  Kultschitzky    and 
Welter's,  355 

stain  for  fat,  347 

eosin,      method     of     staining, 

340 

stain,  339 
Weigert's  iron,  339 
Haemophilia,  100 
clotting  in,  100 
Haemorrhage,  cerebral,  239 

into  pericardium,  49 
Haemorrhagic  diseases,  99 
Haemosiderin  in  liver,  180' 

method    of    demonstrating    in 

tissues,  353 

Hands,  cleansing  of,  44 
Hardening  tissue  for  microscopic 

sections,  329 
Harke's  saw-cut  for  base  of  skull, 


INDEX 


Heart  and  great  vessels,  malfor- 
mations of,  46 

and  pericardium,  disease  of,  46 
aneurysm  of,  57 
auriculo-ventricular  bundle  of, 

73 

brown  atrophy  of,  54 

cloudy  swelling  of,  54 

congenital  abnormalities  of,  46 

development  of,  46 

dilatation  of,  60  - 

"  ectopia  cordis,"  48 

examination  of,  23 

examination  of  excised,  74 

fatty  infiltration  of,  54 

fatty  loading,  54 

gumma  of,  59 

hypertrophy  of,  59 

in  nephritis,  216 

in  pneumonia,  129 

primitive  muscular  tissue  of,  73 

surface  of  examination  of,  24 

syphilis  of,  59 

tumours  of,  60 

valves,  table  of  diameter  and 
circumference  of,  76 

weight  and  measurement  of,  75 
Heart-block,  causes  of,  74 
Hepatitis,  acute,  180 

chronic  interstitial,  185 

suppurative,  181 
Hereditary  spinal  ataxia,  252 
Hernia,  160 

strangulated,  161 
Herxheimer's  method  of  Scharlach 

R.  staining,  349 
Hirschsprung's  disease,  159 
Hiss's  capsule  stain,  369 
"  Hobnailed  "  liver,  187 
Hodgkin's  disease,  104 
"  Honey- comb  "  lung,  119 
Hydatid  cyst  of  liver,  193 

suppuration  in,  182 
Hydatid  mole,  268,  278 
Hydrocephalus,  234 
Hydromyelia,  245 
Hydronephrosis,  275 

congenital,  201 
Hydropericardium,  49 
Hydrothorax,  149 


Hyperemesis  gravidarum,  269 
Hypernephrorna,  114,  224 
Hypertrophy  of  heart,  60 

Incising  organ,  use  of  knife  in,  1 1 
Indian  ink  method,  Burri's,  369 
Infant,  signs  of  maturity  in,  309 
Infanticide,   causes   of   death   in, 

3ii 

Infarction      from     acute     endo- 
carditis, 68 

of  brain,  235 

of  intestine,  161 

of  kidney,  201 

of  liver,  176 

of  lung,  123 

of  placenta,  268 

septic,  of  lung,  131 

of  spleen,  108 
Infections  of  eye,  6 
Infiltration,  fatty,  of  liver,  178 

of  heart,  54 
Ink    method    of     demonstrating 

spirochaetes,  369 
Instruments  for  post-mortem,  7 
Insular  sclerosis,  250 
Intestine,  actinomycosis  of,  166 

chronic  venous  congestion,  161 

dilation  of,  159 

diseases  of,  159 

examination  of,  29 

haemorrhage  of,  162 

hernia  of,  160 

infarction  of,  161 

inflammation  of  large,  167 

inflammation  of  small,  162 

intussusception  of,  160 

malformations  of,  159 

parasites  of,  170 

removal  of,  28 

stenosis  of,  159 

syphilis  of,  166 

tuberculosis  of,  165 

tuberculous  ulceration  of,  165 
table     of     differences     from 
typhoid  ulceration,  166 

tumours  of,  171 

typhoid  of,  163 

typhoid  ulceration  of,  164 

volvulus  of,  159 


INDEX 


385 


Interauricular  septum,  defective, 

46 
Interventricular    septum,    defec- 

tive, 46 

Intussusception,  160 
Iodine  stain  for  waxy  material, 

352 
test  in  waxy  disease  of  arteries, 

77 
Iron-containing  pigment,  demon- 

stration of,  353 
Iron-haematoxylin,  339 
Irritant    poisoning,    appearances, 


Jaundice,  obstructive,  JJpm  pan- 

creatic tumours,  199 
Jenner's  stain,  358 
Joint,  CharCot's,  262 

gouty,  262* 
Joints,  diseases  of,  261 

rheumatoid  arthritis  of,  262 

tuberculosis  of,  261 
Jores's  fixative,  323 

Kaiserling's  fixative,  323 
Kidney,  arterio-sclerotic,  214 

Bright's  disease,  207 

chronic  venous  congestion,  201 

cloudy  swelling  of,  202 

congenital  anomalies  of,  200 

congenital  cystic,  200 

congenital  cysts  of,  200 

degenerations  of,  202 

diseases  of,  200 

examination  of,  35,  224 

fatty    degeneration    associated 
with  Bright's,  203 

fatty  degeneration  of,  202 

hydronephrosis,  225 

in  eclampsia,  271 

infarction  of,  201 

inflammation  of,  204 

large  white,  210 

leukaemia  of,  223 

pigmentary  changes  of,  204 

pyelitis  of,  226 

removal  of,  with  bladder,  32 

suppuration  of,  221 

syphilis  of,  223 


Kidney,  tube  casts  of,  218 

tuberculosis  of,  222 

tumours  of,  223 

waxy  disease  of,  203 

waxy,  in  tuberculosis,  147 
Kultschitzky's  ha3matoxylin,  347 

Laryngitis,  116 

diphtheritic,  116 
Larynx,  diseases  of,  116 

syphilis  of,  117 

tuberculosis  of,  117 

tumours  of,  117 
Leiomyoma,  280 
Leishman's  stain,  358 
Leptomeningitis,  230,  231 

cerebral,  230 

spinal,  246 

Letulle's  method  of  making  post- 
mortem, 14,  42 
Leucocythaemia,  96 
Leukaemia,  96 

liver  in,  191,  97 

kidney  in,  223 

pseudo-,  104 
Levaditi's  stain    for   spirochaetes, 

370 

Lipoma,  279 
Lithium  carmine,  344 
Liver,  abscess  of,  181 

actinomycosis,  182 

acute  yellow  atrophy  of,   182, 
183,  270 

amyloid  degeneration,  179 

chronic  venous  congestion     of, 
175 

circulatory  disturbances  of,  175 

cirrhosis  of,  185 

cloudy  swelling  of,  176 

congenital  syphilis,  189 

deformities  of,  175 

degenerations  of,  176 

diseases  of,  175 

examination  of,  31,  193 

fatty  degeneration  of,  177 

fatty  infiltration  of,  178 

focal  necrosis  in,  178 

gumma  of,  190 

in  eclampsia,  179,  271 

inflammation  of,  180 

25 


386 


INDEX 


Liver,  leukaemia  of,  191 

lymphadenoma  of,  191 

nutmeg,  175 

pigmentary  changes  in,  180 

pigment  in  chronic  venous  con- 
gestion, 1 80 

regeneration  of,  185 

results  of  cirrhosis  of,  189 

subacute  yellow  atrophy,  184 

syphilis  of,  190 

tropical  abscess  of,  182 

tuberculosis  of,  190 

tumours  of,  192 

waxy  degeneration  of,  179 

waxy,  in  tuberculosis*  147 
Lobar  pneumonia,  125 
Lobular  pneumonia,  129 
Locomotor  ataxia,  251 
Lorrain-Smith's    Nile    blue    sul- 
phate stain  for  fat,  347 
Lubarsch's    method    of    demon- 
strating glycogen,  350 
Lugol's  iodine,  350 
Lung,  abscess  of,  131 

acute  congestion  of,  122 

anthracosis,  133 

atelectasis  of,  120 

brown  induration  of,  123 

caseous  tuberculosis,  differences 
from  lobular  pneumonia,  etc., 
143 

caseous  tuberculosis  of,  142 

coal-miner's,  133 

collapse  in  new  born,  medico- 
legal,  310 

collapse  of,  119 

chronic  venous  congestion  of, 
122 

chronic  venous  congestion  with 
tuberculosis,  148 

diseases  of,  119 

emphysema  of,  121 

examination  of,  27,  151 

nbro-caseous  tuberculosis  with 
cavitation,  146 

fibrosis,  146 

gangrene  of,  131 

gumma  of,  135 

haemorrhage  of,  123 

hypostatic  congestion  of,  122 


Lung,      hypostatic      pneumonia, 

132 

infarction  of,  123 
inflammation  of,  125 
in  nephritis,  217 
interstitial  pneumonia  of,  132, 

133 

miliary  tuberculosis  of,  140 

oedema  of,  124 

passive  congestion  of,  122 

pneumokoniosis  of,  133 

pneumonia  of,  125 

septic  pneumonia,  131 

siderosis  of,  134 

silicosis  of,  134 

stone  mason's,  134 

syphilis  of,  134 

tuberculosis  of,  135 
classification,  139 
metastasis,  147 
mode  of  spread,  137 
paths  of  entry  of  infection, 

135 
"  seat  of  election,"  135 

tumours  of,  148 

water     test,     medico-legal    in 
infant,  310 

water  test,  in  pneumonia,  120 
Lymphadenitis,  102 

tuberculous,  103 
Lymphadenoma,  104 

glands  in,  104 

liver  in,  105,  191 

lungs  in,  105 

spleen  in,  105,  110 
Lymphangioma,  281 
Lymphatic  leukaemia,  97 
Lymph  glands,  diseases  of,  102 

examination  of,  102 

pigmentary  changes  in,  102 

tumours  of,  105 
Lymphocythaemia,  97 

blood  in,  98 

bone  marrow  in,  98 

kidney  in,  98 

liver  in,  98 

lymph  gland  in,  98 

spleen  in,  98 
Lymphoma,  282 
Lympho-sarcoma,  282,  289 


INDEX 


Mallory      and     Wright's      eosin, 

methylene  blue  stain,  342 
Mammary  gland,  tuberculosis  of, 
273 

inflammation  of,  272 

tumours  of,  273 
Mann's  methylene  blue  stain,  367 

modification  of  Miiller's  fluid, 

327 
Marchi's  fixative,  328 

staining  method,  356 
Mastitis,  272 
Maturity,  table  of  signs  in    new 

born  of,  309 
Mayer's  hasmatein,  340 
Meckel's  diverticulum,  159 
Medico-legal  post-mortem,  2,  306 

preservation  of  organs  in,  311 

procedure  in,  306 

report  in  England,  308 

report  in  Scotland,  307 

typical  reports,  215,  216 
Medullary  cancer,  302 

sheaths,  staining  of,  354 
Melanotic  tumours,  294 
Meninges  of  brain,  diseases  of,  229 
Meningitis,  cerebral,  229 

cerebro-spinal,  231 

serous,  233 

spinal,  245 

syphilitic,  233 

tuberculous,  232 
Meningocele,  245 
Meningo-myelocele,  245 
Methylated  spirit  as  fixative,  329 
Methylene  blue,  eosin  stain,  341 
Methyl- violet  stain,  353 

in  Much's  method,  366 
Microscopic  examination,  routine 
of,  324 

selection  of  urine  for,  324 
Microscopic   sections,    cutting   in 
gum,  333 

cutting  in  celloidin,  333 

cutting  in  paraffin,  332 

decalcification,  335 

dehydration,  330 

embedding  in  celloidin,  332 

embedding  in  gum,  326 

embedding  in  paraffin,  330 


387 

quick 


Microscopic       sections, 
method,  331 

fixation  of  tissue,  325 

freezing  of,  334 

hardening  of  tissues,  329 

mounting  media,  336 

preparation  of,  324 

staining  methods,  337 
Microtome,  Aschoff- Becker,  334 

Bruce,  333 

Cathcart,  334 

Minot,  333 

Mixter,  334 

making  use  of,  332 

Schanze,  333 
Middle  ear,  examination  of,  40 

association     with     meningitis, 

227 

"  Milk  spots,"  52 
Miller's  method  of  staining  clubs 

of  actinomyces,  368 
Minot,  microtome,  333 
Mitral  valve,  disease  of,  69,  70 

effects  of  disease  of,  70 
Mixed  cell,  sarcoma,  291 
Mixter,  microtome,  334 
Mole,  placental,  304 
Molluscum  contagiosum,  283 
Mordant,  alum,  339 

iron,  339 

Morphia  poisoning,  314 
Mounting,    fluid    for    specimens, 
321 

media  for  sections,  336 

of  specimens,  319 
Mouth,  diseases  of,  153 

tumours  of,  153 

Much-Gram  stain  combined  with 
Ziehl     Neelsen     stain,     366, 

367 
Much's     peroxide     of     hydrogen 

method,  367 
Mucous  colitis,  169 
Muir's  capsule  stain,  368 
Miiller's  fixative,  327 
Muscles,  vitreous  degeneration  of 

Zenker  of,  18 
Muscular     atrophy,     progressive, 

249 
Myelaamia,  96 


388 


INDEX 


Myelin,  degenerated  staining  of,  356 
Myelitis,  246,  247 
Myelocythaemia,  96 

blood  in,  96 

bone  marrow  in,  97 

kidney  in,  97 

liver  in,  97 

spleen  in,  97 

Myeloid  sarcoma,  261,  291 
Myeloma,  261,  293 
Myocarditis,  58 

chronic  interstitial,  58 
Myocardium,  chronic  venous  con- 
gestion of,  53 

degeneration  of,  53 

diseases  of,  53,  55 

fatty  degeneration  of,  55 

syphilis  of,  59 

tuberculosis  of,  59 
Myoma,  280 
Myx oedema,  in 
Myxoma,  278 
Myxoma  of  chorion,  268,  278,  304 

Neisser's  stain  for  diphtheria,  373 
Nephritis,  204 

acute,  208 

table  of  comparison,  219 

blood  in,  217 

cardio- vascular  changes  in,  216 

causes,  208 

chronic  interstitial,  212 

chronic  interstitial  urine  in,  216 

classification,  207 

dropsy  in,  217 

haematogenous,  220 

heart  in,  216 

lungs  in,  217 

changes  in  nervous  system  in,  218 

subacute,  210 

suppurative,  220 
Nerve  sheaths,  staining  of,  354 
Nerves,  diseases  of,  252 

tumours  of,  253 
Nervous  system  in  nephritis,  218 

tissue  embedding  in   celloidin, 

333 
Neuritis,  252 

interstitial,  253 

parenchymatous,  252 


Neuro-fibroma,  253 

New-born,  causes  of  death  of,  311 
infants,  post-mortem  in,  308 
table  of  signs  of  maturity  in,  309 

Nile  blue  sulphate  stain  for  fat, 
347 

Nissl  bodies,  staining  of,  356 

Nitric  acid  as  decalcifying  fluid, 
335 

"  Nutmeg  "  liver,  175 

Oedema  in  cardiac  disease,  72 

of  brain,  233 

of  glottis,  116 

of  lung,  124 

renal,  217 

subcutaneous,  217 
(Esophagus,    corrosive   poisoning 
of,  154 

examination  of,  23 

peptic  ulcer  of,  154 

removal  of,  in  suspected  poison- 
ing, 153 

tumours  of,  154 

varicose  veins  of,  153 
Omphalo-mesenteric  duct,  159 
Orbit,  examination  of,  40 
Organs,  bacteriological  investiga- 
tion of,  360 
Orth's  fixative,  328 

lithium  carmine,  344 

rules  for  making  post-mortem, 

15 

Osmic  acid,  stain  for  fat,  347 
Ossific  node  in  cuboid,  309,  311 

in  femur,  309,  310 
Osteitis  deform ans,  260 
Osteoma,  280 
Osteo-sarcoma,  292 
Ovaritis,  264 
Ovary,  tumours  of,  264 

Pachymeningitis,  cerebral,  229 

acute,  229 

chronic,  230 

hsemorrhagica,  230 

spinal,  245 

Paget's  disease  of  bone,  260 
Pancreas,  cysts  of,  199 

diseases  of,  197 


INDEX 


389 


Pancreas,  examination  of,  32 

fatty  infiltration  of,  197 

relation  to  diabetes,  199 

tumours  of,  198 
Pancreatic  duct,  examination  of, 

3i 

Pancreatitis,  acute  haemorrhagic, 
198 

chronic  interstitial,  198 

fat  necrosis  in,  197 

suppurative,  198 
Papilliferous,      cystic     adenoma, 

265,  285 
Papilloma,  284 

of  larynx,  117 
Papilloma,  mucous,  283 

of  bladder,  228 

squamous,  283 
Pappenheim's  stain,  343 
Paraffin,  embedding  in,  330 

quick  method,  331 
Paraffin  sections,  cutting  of,  332 

fixing  on  slides,  332 

staining  for  bacteria,  363 

treatment  before  staining,  337 
Paralysis,    general,     of     insane, 
242 

infantile,  248 
Parasites  of  alimentary  tract,  170 

of  bladder,  228 
Parathyroids,  28 
Pathologist,  equipment  of,  5 

infection  of  eye,  6 

wound  of  finger  of,  6 
Perenny's  decalcifying  fluid,  335 
Pericarditis,  acute,  50 

chronic,  52 

classification  of,  51 

results  of,  52 

tuberculous,  53 
Pericardium,  adherent,  52 

air  in,  50 

anatomy  of,  48 

blood  in,  49 

diseases  of,  46,  48 

dropsy  of,  49 

incision  of,  19 

tuberculosis  of,  53 
Perihepatitis,  180 
Perithelioma,  292 


Peritoneum,  ascites  of,  172 

diseases  of,  172 

haemorrhage  of,  172 

tuberculosis  of,  173 

tumours  of,  174 
Peritonitis,  acute,  172 

chronic,  173 

tuberculous,  173 
Pernicious  anaemia,  93 

bone  marrow  in,  94 

colour  index,  95 

heart  in,  93 

intestines  in,  94 

kidney  in,  94 

liver  in,  93 

lungs  in,  93 

red  blood  corpuscles  in,  95 

skin  in,  93 

spinal  cord  in,  95 

spleen  in,  94 

stomach  in,  94 

subcutaneous  fat  in,  93 

white  blood  corpuscles  in,  95 
Phlebitis,  89 
•     results  of,  90 
Phosphorus  poisoning,  313 
Phthisis,  140 

fibroid,  144 
Pick's  fixative,  322 
Picro- car  mine,  340 

methods  of  staining  with,  338 
Picro- fuchsin,  340,  341 
Pipettes,  method  of  making,  375 
Placenta,  diseases  of,  268 
Plasma  cells,  staining  of,  343 
Pleura,  diseases  of,  149 
Pleural  cavities,  examination  of, 

19 
Pleural  cavity,  dropsy  of,  149 

gas  in,  150 
Pleurisy,  150 

chronic,  151 

classification,  150 

in  tuberculosis,  151 
Plexiform  angioma,  281 
Pneumokoniosis,  133 
Pneumonia,  125 

broncho,  129 

catarrhal,  129 

congestion  of  spleen  in,  129 


39° 


INDEX 


Pneumonia,  croupous,  125 

grey  hepatisation,  127 

heart  in,  129 

hypostatic,  132 

interstitial,  132,  133 

leucoblastic  marrow  in,  129 

lobar,  acute  congestion  in,  126 

lobar,  causes  of,  125 

lobular,  129 

other  organs  in,  129 

red  hepatization,  126 

resolution  in,  128 

septic,  131 

syphilitic,  135 

tuberculous,  142 

types  of,  125 

white,  134 

Pneumopericardium,  50 
Pneumothorax,  150 
Poisoning,  ammonia  gas,  314 

carbon  monoxide,  313 

chloroform,  314 

cyanide,  314 

irritant,  313 

morphia,  314 

phosphorus,  313 

ptomaine,  314 

strychnine,  314 

vegetable,  314 
Poisons,  post-mortem  changes  in 

organs. from,  311 
Poliomyelitis,  248 
Polychrome  methylene  blue,  353 
Polypi,  277 
Portal  pyaemia,  181 
Portal  vein,  embolus  of,  176 

thrombosis  of,  176 
Post-mortem,  i 

hospital  regulations  for,  2 

importance  of  changes,  4 

in  private,  9 

instruments  for,  7 

Letulle's  method,  14,  42 

medico-legal,  2,  3 
procedure  in,  306 

notes  of,  9 

object  of,  13 

permission  for,  2 

primary  incision,  17 

procedure  in  making,  13 


Post  -  mortem,        reflection       of 

muscles,  etc.,  17 
rules  for  examining  organ  at,  10 
Shennan's  method  of,  43,  21 
surface  examination,  15 
table  and  accessories,  8 
wounds,  treatment  of,  6 
Post-mortem  report,  medico-legal, 
in  England,  308 
in  Scotland,  307 

Post-mortem  medico-legal,  speci- 
men reports,  215,  216 
Post-mortem  room,  equipment  of, 

9 

solutions,  etc.,  for,  8 
Pregnancy,  diseases  of,  269 
Preparation  of  tissue  for  dispatch, 

329 

Preservative,  Frost's,  323 
Primary  incision  at  post-mortem, 

17 

Procurator-fiscal,  2,  3,  307 
Progressive  muscular  atrophy,  250 
Prostate,  diseases  of,  274- 

hypertrophy  of,  274 

tumours  of,  274 
Prostatitis,  acute,  274 
Prussian  blue  reaction,  94 
Psammoma,  293 
Ptomaine  poisoning,  314 
Puerperium,  diseases  of,  269 
"  Pulmonary  apoplexy,"  123 

artery,   congenital    stenosis  of, 

47 

examination  of,  23 
tuberculosis,  135 
valve,  lesions  of,  72 
Purpura,  99 
Pus,    examination    for    tubercle 

bacillus,  371 

making  of  films  from,  362 
Pyelonephritis,  221 
Pyloric  stenosis,  congenital,  155 
Pyopneumothorax,  150 
Pyorrhoea  alveolaris,  153 
Pyronin-methylgreen  stain,  343 

Red  hepatization  of  lung,  126 
Redressing  of  body,  44 
"  Red  softening,"  281 


INDEX 


391 


"  Red  staining  of  intima,"  60 
Removal  of  organs  from  thorax 
and  abdomen,  20 

Shennan's  method,  21 
Resolution  of  lung,  128 
Resorcin-fuchsin  stain,  344 
Respiratory  system,  diseases  of, 

116 

Reynold's  capsule  stain,  368 
Rhabdomyoma,  280 
"  Rice  water  stools,"  163 
Rickety  rosary,  18,  255 
Rigor  mortis,  16 
Rodent  ulcer,  299 
Round  cell  sarcoma,  large,  290 

small,  289 
Rules  for  examination  of  an  organ 

at  a  post-mortem,  10 
Russell's  "  fuchsin  bodies,"  297 

Sago-waxy  spleen,  105 
Salpingitis,  265 
Sarcoma,  287 

alveolar,  292 

angio-,  293 

characteristics  of,  287 

chondro-,  292 

classification  of,  288 

difference   from  granulation 
tissue,  291 

large  round  cell,  290 

large  spindle  cell,  290 

lympho-,  289 

melanotic,  294 

mixed  cell,  291 

myeloid,  291 

of  bone,  260 

of  brain  243 

of  heart,  60 

of  intestine,  171 

of  kidney,  223 

of  larynx,  117 

of  liver,  193 

of  lymphatic  glands,  105 

of  nerve,  253 

of  ovary,  265 

of  spleen,  no 

of  stomach,  158 

of  testicle,  274 

of  vertebrae,  252 


Sarcoma,  osteo-,  292 

small  round  cell,  289 

small  spindle  cell,  290 

sites  of  origin  of,  289 
Schanze  microtome,  333 
Scharlach  R.  stain  for  fat,  348 
Schering's  celloidin,  332 

formalin,  323 
Scirrhous  cancer,  301 
Sclerosis  of  spinal  cord,  247 

disseminated,  250 
Scurvy,  99 

infantile,  99 
Sectio  cadaveris,  i 
Serous    sacs,    bacteriological    in- 
vestigation of,  361 
examination  of,  19 
Shennan's      method      of      post- 
mortems, 21,  43 
Siderosis  of  lung,  134 
Silicosis  of  lung,  134 
Sino- auricular  node,  73 
Sinuses,  accessory,    of   head,  ex- 
amination of,  40 
Skull,    fracture    of,    examination 

for,  35 

Slides,  cleaning  of,  336 
Soft  cancer,  302 
"  Soldier's  spots,"  52 
"  Soul  and  Conscience,"  form  of 

report,  4,  307 

Specimens,  method  of  mounting, 
321 

mounting  of,  319,  321 

preparation    for    transmission, 

329 

preservation  of,  319 

preservation  of,  in  medico-legal 

work,  307 
Spina  bifida,  244 

occulta,  245 

Spinal    cord,    congenital    abnor- 
malities of,  244 

diseases  of,  244 

examination  of,  39 

gumma  of,  252 

inflammation  of,  246 

named  diseases  of,  248 

tuberculosis  of,  252 

tumours  of,  252 


392 


INDEX 


Spindle  cell  sarcoma,  large,  290 

small,  290 

Spirochaetes  in  atheroma  lesion, 
80 

in  tissues,  staining  of,  370 

methods  of  staining,  369 

in  brain,  242 
Spleen,  acute  congestion,  107 

atrophy  of,  105 

chronic  venous   congestion   of, 
107 

circulatory  disturbances,  107 

diseases  of,  105 

examination  of,  30,  32,  111 

iron  pigment  in,  107 

hyaline  degeneration  of,  106 

in  Banti's  disease,  95 

infarction  of,  108 

inflammation  of,  109 

in  pneumonia,  129 

lymphadenoma  of,  105,  110 

miliary  tuberculosis  of,  109 

pigmentation  of,  106,  107 

tuberculosis  of,  109 

tumours  of,  no 

waxy  degeneration  of,  105,  147 
Splenic  anaemia,  95 
Splenomedullary  leukaemia,  96 
Sputum,  examination  for  tubercle 
bacillus,  370 

making  of  films  from,  361 
Squamous  epithelioma   (see  Epi- 
thelioma),  297 

papilloma,  283 
Staining  methods,  337 

sections,    apparatus    required, 

335 
Sterno-clavicular  joint,  disarticu- 

lation  of,  18 

Sternum,  removal  of,  18,  19 
Stomach,  acute  catarrh  of,  155 
chronic  catarrh  of,  156 
chronic  venous   congestion   of, 

155 

congenital  pyloric  stenosis,  155 
dilatation  of,  155 
diseases  of,  154 
effect  of  acids  on,  156 
examination  of,  30 
fibromatosis  of,  158 


Stomach,    haemorrhagic    erosions 
of,  155 

hour-glass  contraction  of,  155 

post-mortem  digestion  in,  155 

suppurative  catarrh  of,  156 

tumours  of,  158 

ulcer  of,  157 
Stone  in  bladder,  228 
"  Stone-mason's  lung,"  134 
Streptothrix  actinomyces,     stain- 
ing of  club  forms,  268 
Strychnine  poisoning,  314 
Struma,  112 
Subacute  nephritis,  210 

urine  in,  212 
Subacute      atrophy      of       liver, 

184 

Sudan  III.  stain  for  fat,  348 
Sudden  death,  arteries  in,  77 

examination      o'f      coronary 

arteries  in,  26 
in   relation    to    haemorrhage 

into  supra-renals,  114 
thymus  gland  in,  28 
Supra-renals,  accessory,  114 

diseases  of,  113 

examination  of,  33 

haemorrhage  into,  114 

hypernephroma,  114 

removal  of,  33 

structure  of,  113 

tuberculosis  of,  114 

tumours  of,  114 
Surgical  kidney,  221 
Syphilis,     congenital,     of     liver, 
189 

of  arteries,  80,  84 

of  bone,  260 

of  brain,  241 

of  bronchi,  119 

of  heart,  59 

of  intestine,  106 

of  kidney,  223 

of  larynx,  117 

of  liver,  189,  190 

waxy  degeneration  in,  190 

of  lung,  134 

of  meninges,  233 

of  testicle,  273 
Syringomyelia,  245 


INDEX 


393 


"  Tabby  cat  "  heart,  55 
Tabes  dorsal  is,  251 
Tabloids  for  making  stains,  358 
Teratoma,  303 

of  ovary,  265 
Test    for    carbon    monoxide    in 

blood,  314 

Testicle,    chorionepithelioma    of, 
304 

diseases  of,  273 

examination  of,  35 

fibrosis,  273 

gumma  of,  273 

removal  of,  35 

syphilis  of,  273 

tuberculosis  of,  273 

tumours  of,  274 
Thoracic    contents,    examination 

of,  22,  23 
Thoracic    duct,    examination  of, 

35 

Thrombi,  61,  88 

Thrombosis,  in  vessels  of  brain, 
235 

of  portal  vein,  176 

of  uterine  veins,  266 

of  veins,  87 
Thrombus,  red,  88 

septic,  softening  of,  88 

simple,  88 

white,  88 

"  Thrush  breast  "  heart,  55 
Thymus  gland,  28 
Thyroid  gland,  diseases  of,  in 

examination  of,  28,  113 

tumours  of,  112 

waxy  degeneration  of,  112 
Tissues,  preparation  of,  for  micro- 
scopic examination,  324 
Tricuspid  valve,  diseases  of,  72 
Tropical  abscess  of  liver,  182 

associated  with  dysentery,  182 
"  Tube  casts,"  218 
Tubercle    bacillus,    concentration 
method    of     examining    for, 

371 
extraction    with    acetone    and 

ether,  372 

in  sections,  staining  of,  366 
in  sputum,  examination  for,  370 


Tubercle    bacillus,     Much  -  Gram 

stain,  366 

Ziehl-Neelsen  method,  365 
staining  for,  365 
Tuberculosis,  arteries  in,  84 
miliary,  of  lung,  140 
of  bladder,  227 
of  bone,  259 
of  brain,  241 
of  breast,  273 
of  epididymis,  273 
of  Fallopian  tubes,  265 
of  heart,  59 
of  intestine,  165 
of  joints,  261 
of  kidney,  222 
of  larynx,  117 
of  liver,  190 
of  lung,  135 

broncho- pneumonic,  142 

caseous,  142 

changes     in     other     organs, 
147 

classification  of,  139 

nbro-caseous,  144,  147 

hypertrophy    of     heart     in, 
'i47 

interstitial,  147 

mode  of  spread,  137 

paths  of  entry  of  infection, 
135 

"  seat  of  election,"  135 

waxy  disease  in,  147 
of  myocardium,  59 
of  pericardium,  53 
of  peritoneum,  173 
of  spinal  cord,  252 
of  spleen,  109 
of  suprarenal,  114 
of  testicle,  273 
pleurisy  in,  151 
Tuberculous  enteritis,  165 
lymphadenitis,  103 
meningitis,  232 
pneumonia,  142 
ulceration  of  intestine,  164 
Tumours,       difference      between 
"  simple  and  malignant,  275 
epithelial,  283 
malignant,  286 


394 


INDEX 


Tumours,    myxoma    of    chorion, 

304 

neuroglial,  282 

of  bladder,  228 

of  bone,  260,  280 

of  brain,  242 

of  cartilage,  279 

of  fatty  tissue,  279 

of  gall  bladder,  197 

of  heart,  60 

of  intestine,  171 

of  kidney,  223 

of  larynx,  117 

of  liver,  192 

of  lung,  148 

of  lymph  gland,  105 

of  lymphoid  tissue,  282 

of  mammary  gland,  273 

of  mouth,  153 

of  muscle,  280 

of  myxomatous  tissue,  278 

of  myocardium,  60 

of  nerves,  253 

of  O3sophagus,  154 

of  ovaries,  264 

of  pancreas,  198 

of  peritoneum,  174 

of  placenta,  268 

of  prostate,  274 

of  spinal  cord,  252 

of  stomach,  158 

of  suprarenal,  114 

of  testicle,  274 

of  uterus,  268 

of  vascular  tissue,  281 

of  vertebrae,  252 

simple,  277 

types,  275 
Typhoid  carriers,  195 

fever,  163 
kidney  in,  164 
liver  in,  164 
spleen  in,  164 

ulcers  compared  with  tuber- 
culous ulcers  of  intestine, 
166 

Ulcer,  rodent,  299 
Unna's  alkaline  methylene  blue, 
343 


Unna-Pappenheim  stain,  343 
Urine  in  acute  nephritis,  210 

in  chronic  interstitial  nephritis, 
216 

in  subacute  nephritis,  212 
Uterus,  diseases  of,  266 

examination  of,  34 

rupture  of,  269 

tuberculosis  of,  267 

tumours  of,  268 

Valves  of  heart,  abnormalities  of, 

47 
diameter  and  circumference  of, 

76 

examination  of,  24,  25,  26 
Van  Gieson  stain,  method  of  use, 

34i 

Varicose  veins,  89 

Veins,  diseases  of,  87 
thrombosis  of,  87 
varicose,  89 

Venae  Cavae,  examination  of,  23, 
35 

Vermiform    appendix,    examina- 
tion of,  30 

Vertebrae,  tumours  of,  252 

Virchow,    opening   of   abdominal 
cavity,  14 

Viscera    (hollow)    bacteriological 
investigation  of,  360 

Volvulus,  159 

Von  Kossa  silver  stain,  352 

Water  test  for  lungs,  310 
Waxy     degeneration     in     tuber- 
culosis, 147 

of  arteries,  78 

of  liver,  179 

disease  of  kidney,  203 

of  spleen,  105 

material,  anilin  stains  for,  353 
iodine  stain  for,  353 
methyl-violet  stain  for,  353 
stains  for,  352 

Weigert's         borax  -  ferricyanide 
differentiating  mixture,  347 

elastic  stain,  344 

fibrin  stain,  345 

iron-hsematoxylin  stain,  339 


INDEX 


395 


Weigert's  medullary  sheath  stain, 

354 

modification  of  Gram's  stain,  363 
White  softening,  236 
Widal  reaction,  374 
Woolsorter's  disease,  2 
Wright's  stain,  358 


Zenker's  degeneration  of  muscle, 

18 

fixative,  327 
Ziehl-Neelsen   stain    for   tubercle 

bacillus,  365 
Ziehl-Neelsen    with    Much-Gram 

stain,  369 


THE   END 


Printed  by  R.  &  R.  CLARK,  LIMITED,  Edinburgh. 


397 


FIG.   i.— Method  of  opening  the  abdominal  cavity. 


FIG.  2. — Reflecting  the  skin  and  muscles  from  the  sternum  and  ribs. 


26 


FIG.  3. — Method  of  cutting  through  sterno-clavicular  joint. 


FIG.  4. — Method  of  cutting  through  floor  of  mouth. 


399 


^(bfc : 

x 


O   X    Xrt 

'TO 

=  art  fa 


400 


401 


FIG.  9. — Method  of  removing  the  small  intestine. 


FIG.  10. — Method  of  opening  the  bowel  after  it  has  been  removed. 


402 


4^3 


FIG.  13. — Method  of  incising  the  kidney. 


FIG.  14. — Method  of  stitching  [up. 


404 


405 


FIG.  17. — Heart,  chronic  interstitial 
myocarditis.      ^. 

Apical  portion  of  left  ventricle  showing  white 
patches  of  fibrous  tissue  replacing  the  muscle  sub- 
stance. The  change  is  most  marked  at  the  apex  and 
in  the  right  papillary  muscle,  which  has  been  cut 
open. 


FlG.  1  8.  —  Section  through  wall 
of  right  ventricle,  showing  in- 
crease of  sub-pericardial  fat  and 
fatty  infiltration  of  the  muscle.  \. 


FIG.  19.  —  Thrombus  in  right  auricular  appendix. 


406 


FIG.  20. — Heart  of  child,  simple  (vegetative)  endocarditis 
in  a  case  of  chorea,      y. 

Minute  rounded  vegetations  covering  mitral  valve  close  to  free  margin. 


407 


FIG.  21. — Aortic  valve,  simple  endocarditis.      ^. 

Vegetations  along  margin  of  two  segments,  with  red  thrombus 
attached  to  one  of  the  vegetations. 


FIG.  22. — Heart,  ulcerative  endocarditis  of  mitral  valve.     ^. 

The  valve  has  been  the  seat  of  a  previous  endocarditis  as  evidenced  by  the 
thickening  of  the  segments  and  of  the  chordae  tendineae.  Both  sets  of  structures 
are  covered  with  vegetations,  which  also  extend  on  to  the  wall  of  the  left  auricle 
and  chordae  tendineae.  The  wall  of  the  left  ventricle  is  thickened,  and  the  cavity 
dilated,  due  to  the  incompetence  of  the  mitral  valve  which  existed  previous  to  the 
ulcerative  endocarditis.  One  or  two  of  the  chordae  tendineae  have  ruptured. 


408 


FIG.  23. — Ulcerative  endocarditis,  aortic  valve. 
The  segments  had  been  thickened  previously.     They  are  covered  with  vegetations.     One 
of  the  segments  has  ruptured.     There  are  also  vegetations  visible  on  the  mitral  valve  to  the 
right.    There  is  marked  dilatation  of  the  left  ventricle,  largely  due  to  the  incompetence  of  the 
previously  thickened  valve. 


FIG.  24. — Transverse  section  of  heart.      ^. 
Marked  hypertrophy  of  left  ventricle  in  case  of  chronic  nephritis.     Right  ventricle  dilated. 


409 


410 


FIG.  27. — Chronic  endocarditis  of  aortic  valve,    y. 

Calcareous  deposits  in  the  thickened  cusps,  also  union  ot  the  segments 
with  consequent  s.enosis. 


FIG.  28. — Portion  of  descending  thoracic  FIG.  29. — Arteries  at  base  of  brain.      |. 

aorta.       2.  Showing  white  patches  of  atheromatous  change. 
Showing  advanced  atheroma.     Thrombi  have 
formed  in  one  or  two  places. 


FIG.  30. — Saccular  aneurysm  of  descending  aorta  adherent  to  and  eroding 
the  bodies  of  the  vertebrae.     £. 


412 


•S  s 

•"     U 


33 


•3..S  "2<S& 

C/2    G  v  3  8 

[I  *«i 

^i  ill 


413 


1 


FIG.  34. — Spleen  and  spleniculus, 
sago  waxy.      ^. 


FIG.  35. — Spleen,  Hodgkin's  disease,  showing  numerous 
scattered  white  masses  varying  in  size.     |. 
The  organ  is  considerably  enlarged. 


FIG.  36.  —  Spleen,  Hodgkin's  disease.      (Dr.  Byrom  Bram  well's  case.) 
Suet-like  areas  forming  large  tumour-like  masses. 


27 


CO  w 

^  rt 

Q  1 

0) 

-5T  ^ 

U3  ® 


ss  -a 

§  I 

G  W> 

OJ  _ 

T3  rt 


|    8 
"S,  *° 

Si 


4^5 


P   .2 


II 


416 


FIG.  41. — Lung,  collapse  due  to  empyema. 
Thickening  of  parietal  and  visceral  pleura. 


417 


FIG.  42. — Lung,  lobar  pneumonia.     |. 

The  whole  of  the  upper  lobe  and  the  upper  portion  of  the  lower  lobe  are  consolidated 
and  in  the  stage  of  grey  hepatisation.     The  lower  portion  of  the  lower  lobe  is  congested. 


4i8 


FIG.  43. — Lung  and  bronchi,  showing  acute  bronchitis  and  septic 
broncho-pneumonia.      ^. 

The  bronchitis  is  indicated  by  the  congested  mucous  membrane  of  the  bronchi,  the 
broncho-pneumonia  by  the  ill-defined  pale  areas  of  consolidation  scattered  through  the 
lung. 


419 


420 


M^H 

a*sS&SKfe'. 


>•'•    -*>-v--/*> 

4  •- 

-:i-#     V 


FIG.  47. — Lung,  silicosis.      (Dr.  J.  D.  Comrie's  collection. )     ^. 

Raised,  hard,  grey  areas,  surrounded  with  black  pigment,  scattered  in  groups 
under  pleura,  around  vessels  and  bronchi,  and  along  interlobular  septa. 


421 


422 


m 


A  \ 


FIG.  51. — Lung,  caseous  (tuberculous)  pneumonia  vv 
cavitation.      ^. 


•ith 


There  is  caseous  consolidation  of  the  upper  portion,  with  numerous 
acute  cavities.  In  the  lower  portion  there  are  groups  of  tubercles 
arranged  in  a  staphyloid  manner  indicating  lymphatic  spread.  The 
pleura  is  thickened. 


423 


424 


te-r— 


425 


FIG.  58. — Peptic  ulcer  of  stomach,  with 
opening  into  vessel  in  floor  of  ulcer.    ^. 


FIG.  59.  —  Large  duodenal  ulcer. 
(Dr.  Cattenach's  case.  )     £. 


:G.  57.  — Squamous  epithelioma  of  oesophagus,         Pancreas  forming  floor.     Opening  into  large 
with  marked  narrowing  of  lumen.    ^.  vessel  at  one  point",  from  which  fatal  haemor- 


rhage  occurred. 


426 


FIG.  60.  — Stomach  opened  up  anteriorly  to  display  encephaloid  cancer 
close  to  cardiac  opening.      ^. 


427 


FIG.  61. — Intussusception  of  small  intestine  and 
mesentery  into  large.     \. 

Wall  of  large  intestine  has  been  removed  at  one  point, 
showing  congested  bowel  within. 


FIG.  62. — Typhoid  lesion  of  small 
intestine.      ^. 

Early  stage,  showing  swelling  of  Peyer's 
patch  and  solitary  follicles. 


FIG.  63.. — Typhoid  lesion  of  small 
intestine.      |. 

Later  stage,  with  necrosis  of  swollen 
patch  and  formation  of  slough. 


FIG>  64. — Tuberculous  ulcer,  lower 
portion  of  ileum.      \. 

Note  transverse  direction,  raised  margin, 
and  irregular  floor. 


FIG.  65. — Tuberculous  ulcer,  peri- 
toneal aspect,  showing  raised  tubercles 
under  peritoneum.  ^. 


428 


FIG.  66. — Large  intestine,  ulcerative  colitis  (dysentery).     ^. 

Lines  of  hypertrophied  mucous  membrane  with  ulcerated  surfaces  between, 
in  which  the  muscular  coat  is  laid  bare. 


FIG.  67. — Portion  of  large  bowel  from  case  of  amoebic  dysentery, 
showing  characteristic  early  lesion.      ^. 

Minute  crater-like  ulcers  with  central  slough. 


429 


FIG.  68. — Acute  appendicitis  and  peritonitis.      \. 

The  appendix  is  swollen  and  congested,  and  has  ruptured  at  two  points. 
The  portion  of  small  intestine  seen  is  covered  in  part  with  a  thick  layer  of 


fibrinous  exudate. 


FIG.  69. — Pelvic  colon  with  adeno-carcinoma  projecting  into  interior. 
The  wall  of  the  gut  is  hypertrophied  above. 


430 


FIG.  70. — Peritoneal  aspect  of  loop  of  intestine  showing  tuberculous  peritonitis.     \. 
There  are  also  swellings  in  the  mesentery  from  enlarged  mesenteric  glands. 


FIG.  71. — Abscesses  of  liver,  portal  pyaemia  type.      \. 
A  thrombus  is  seen  projecting  from  one  of  the  branches  of  the  portal  vein  (A) 


FIG.  72.— Liver,  large  tropical  abscess  with  much  necrotic  liver  tiss 


FIG.  73. — Liver  of  child  showing 
nultiple  nodular  hyperplasia  (re- 
generation of  liver  substance)  follow- 
ng  an  acute  degenerative  process. 
Dr.  Byrom  Bramwell's  case.  A. 


FIG.  74. — Liver,  common  cirrhosis.     £. 
^  Surface  of  organ  shows  "  hob-nail  "  projections.     Sec- 
tion shows  areas  of  liver  tissue  varying  in  size   seoar- 

nl-^rl    fr^rr,    ^,-,0   -.-.^k^,.  U,,   1 J.,    -r_-__ _•  .•  ^ 


432 


§        § 


433 


1 


o 

£ 


434 


FIG.  80. — Biliary  calculi  or  gall-stones.     ^ 

«,  common  facetted  type. 
/',  mulberry  type. 

c,  rounded,  solitary  stone  composed  of  pure 
cholesterin. 


FIG.  81. — Congenital  cystic  kidney,      i. 

Rounded  spaces,  varying  greatly  in  size,  some  empty, 
others  containing  translucent  gelatinous  material. 


FIG.  82. — Infarcts  of  the  kidney.    ^. 

Three  infarcts  varying  in  size  are  seen 
in  the  upper  part  of  the  organ. 


435 


436 


FlG.  87.  —  Kidney,  pysemic  abscesses. 
Cut  surface. 


FIG.  88.  —  Kidney,  pysemic  abscesses.      \. 
Surface  with  capsule  stripped. 


FIG.  90. — Kidn 


berculosis. 


FIG.  89. — Kidney,  tuberculosis.     |. 


Partial  destruction  of  renal  tissue  form- 
ing cavities  with  ragged  walls,  and  with 
a  zone  of  caseous  tissue  around. 


Acute  type  of  the  disease.  Large  masses  of  tuberculous 
foci  scattered,  mainly  in  groups,  through  organ.  Pelvis 
lined  with  zone  of  caseous  tissue. 


437 


o 

6 


o 
£ 


FIG.  94. — Brain,  showing  acute  meningitis.      ^. 

There  is  general  prominence  of  the  vessels  and  exudate  in  the  sulci  and  fissures, 
especially  the  Sylvian  fissure. 


FIG.  95. — Brain,  tuberculous  meningitis.      -|. 

Exudate  extending  up  the  Sylvian  fissure  and  breaking  up  into  discrete  foci  (tubercles)  along 
the  distribution  of  the  smaller  arteries  in  the  sulci  and  over,  the  convolutions. 


439 


2,        s 


* 


§1  1 


i 


440 


FIG.  98. — Cerebellum  with  depressed 
areas  from  softening  of  brain  substance 
due  to  thrombosis  in  arteries.  ^. 


FIG.  99. — Vertical  section  of  brain,  showing  large  solitary  abscess 
in  temporo-sphenoidal  lobe.      ^. 


FIG.  loo. — Transverse  section  of  pons,  showing  haemorrhages 
into  its  substance.     ^. 


441 


I  -a '5 
S>|o 

M  fa/) 

o  .S 


442 


FIG.  104. — Myomata  in  wall  of  uterus.     \. 
a.,  subserous  type.        6,  intramural  type.        c.  submucous  type.       d  indicates  position  of  os  uteri. 


FlG.  105. — Enlargement  of  costo-chondral  junctions  (rickety  rosary)  in  rickets.      \. 


443 


FIG.  107.  —Lower  lumbar  vertebrce  and  sacrum 
in  section.      ^. 

Showing  destruction  of  the  body  of  one  vertebra  (A), 
with  abscess  containing  caseous  material  extending  from 
it  anteriorly,  the  cauda  equina  being  pressed  upon  behind. 
The  body  of  the  vertebra  above  shows  infiltration  with 
tuberculous  foci. 


FIG.    106. — Chronic  osteomyelitis 
of  lower  end  of  femur.      |. 

A  new  casing  of  bone  is  seen  above, 
below  is  necrosed  bone  with  openings 
(cloacae). 


444 


FIG.  109. — Myeloid  sarcoma 
of  jaw.      f . 

T  indicates  three  teeth. 


FIG.  108. — Osteo-sarcoma  of  shaft 
of  femur.     ^. 


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